GW1-2023-02206_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information: FROM TO DESCRIPTION
WILLIAMLAWSON 173 ft. 174 ft.
Well Contractor Name ft. ft.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNESE MATERIAL
CHEROKEE WELL DRILLING 0 R• 85 ft- 6.125 in^ SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000744 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction pertm its ft County,State,Variance,etc. ft. ft. in.
3.Well Use: ft. ft. in.
17.SCREEN I
FROM TO DIAMETER THICKNES SLOT S MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 20ft.
ft
��73 ft. ft.
M AR 19.SAND/GRAVEL PACK(if applicable)
_.�;�;:,;'•',-,:;.;;;:�Ur"" FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
itf;2s•n, ',i�, ft. ft.
i=''d�.�;a•%'�=
4. Date Wel(s)Completed: 2/17/2023 Well ID# CRISP/DAVIS/RAPER ft. ft.ft. ft.
Sa. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits ft County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
SHARON WHITEHEAD 599/129 0 ft. 67 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 67 ft. 85 ft. Gray Hard Granite Set Casing
630 MCCLURE RD MURPKY 28906 Lot 85 ft. 173 ft. Gray Hard Granite
Physical Address,City,and zip 173 ft. 174 ft. Gray Hard Granite Small Fracture 2 GPM
Cherokee 458118317256000 174 ft. 405 R Gray Hard Granite
County Parcel Identification No.(PIN) ft. ft.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one tat/long is sufficient.) 21.REMARKS
35.04905 N -84.068003 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. C rti
7. Is this a repair to an existing well: No 2/20/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well ontractor Date
repair under#11 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been provided to the well owner.
For multiple injection or non-water wells ONLY with the same construction,you can 23. Site diagram or additional well details:
submit oneform. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 405 (ft.)
For multiple wells list all depths if different(example-3@ 100'and 1 @ 1009 SUMITTAL INSTRUCTIONS
24s.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 80 (ft.) construction to the following:
Ifwater level is above casing,use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13s. Yield(gpm): 2 Method of test: Alr 24c.For Water Supply lniection Wells: In addtion to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 100 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deaartment of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013