GW1-2023-02207_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
WILLIAM LAWSON 239 ft. 241 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 THICKNES1 MATERIAL
CHEROKEE WELL DRILLING 0 ft. 60 ft. 6.125 in• SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop) i
2.Well Construction Permit#: W2022000723 2022000629 FROM TO DIAMETER THICKNES MATERIAL
List all applicable well construction peranits ft County,State,Varlanee,eta ft ft. in.
3.Well Use: ft. ft. in.
17.SCREEN j
FROM TO DIAMETER THICKNES SLOT SIZI MATERIAL
Residential ft. ft. in.
ft ft in.
r^ ? 1 18.GROUT i
FROM TO MATERIAL EMPLACEMENT METHOD 8t AMOUNT
t. 20 ft.
ft. ft.
19.SAND/GRAVEL PACK(if applicable) j
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 2/24/2023 Well ID# TARHEEL NORTH ft. ft.ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(le County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
RIDE AND RELAX LLC TR 555 0 ft. 41 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 41 ft. 60 ft. Gray Hard Granite Set Casing
2394 TARHEEL DR MURPHY 28906 Lot 60 ft. 239 ft. Gray Hard Granite
Physical Address,City,and Zip 239 ft. 241 ft. Gray Hard Granite Large Fracture 24 GPM
Cherokee 458212863414000 241 M 305 ft. 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 lattlong is sufficient.) 21.REMARKS j
35.09105 N -84.056627 W BIT SIZE 5.92"
6. Is(are)the weli(s): Permanent
22. ertifcation•
7. Is this a repair to an existing well: No ��� 2/27/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well ClIntractor Date
repair under#21 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 15A NCAC 02C.0100 or 15A 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 one form. 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: 305 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 160 (D') construction to the following:
Ijwater 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 24b.For Infection 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: ; 1
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 24 Method of test: Air 24c.For Water Sunnily-Iniection 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. ' i
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013