GW1-2023-02564_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14_.1 ATER.ZO_NES.__1.`Yell Contractor Information _
FROM TO DESCRIPTION
WILLIAM LAWSON 79& 80 ft.
Well Contractor Name 258 ft. 260 fL
NCWC3491 A 19.OUTER CASING(for multi-cased wells)OR I I1rER(rf appircavle}`
z
NC Well Contractor Certification Number FROJr1 TO DIAMETER THICKNESS \MATERIAL
CHEROKEE WELL DRILLING 0 % 23 6.125 a"• SDR 21 PVC plastic
Company Name fL fL in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit 9: W2022000136 2019000264 FROM TO DIANMTER THICKNESS IVIATERIAL
List all applicable well construction pertnuts(ie County,Stag Variance,etc. ft. ft in.
3.Well Use: it. ft "r'
17.SCREEN
FROM TO DIANIETER THICKNESS I SLOT SIZE IMATERIAL
Residential ft_ ft_ in.
ft: & in.
18_GROUT
_ = FROM TO A4ATERLAL MvfPLACENEWIvMTHOD&AMOUNT•
ft. ft.
APR 1 0 2023 ft. ft.
^� ,,:. 19:SANS/GRAVELPACI:(ifapplicable)
U "i
'" r �"'`, FRONT TO MATERIAL t- ENIPLACEAdF-NT METHOD AIAOUNT`
�•�d y;rl u',6-7
ft. M
4. Date Well(s)Completed: 3/14/2023 NWH ID# MAX PAYNE PROP ft_ ft_
ft. ft_
51. Well Location: 20.DRILLING LOG(attach additional sheets ifnecessarr)
List all applicable well construction pertmits(ie County,State,Variances eta FRONT TO I DESCRIPTION(color,hardness,soiUrocl:type,grain size,etc)
JUSTIN PELZER LOT 17 0 ft_ 7 ft_ Brown Medium Slate
Facility/Owner Name Facility ID(ifapplicable) 7ft. 23 ft. Gray Hard Granite SET CASING
200 CABIN WAY MURPHY 28906 Lot 23 fL 79 ft. Gray Hard Granite
Physical Address,City,and Zip . 79 ft. 80 ft. Gray Fractured Granite SMALL FRACTURE 5 GPM
Cherokee 4566900258473000 80 ft_1258 ft Gray Hard Granite "
County Parcel Identification No.(PliM) 258 ft 260 fL Gray Fractured Granite LARGE FRACTURE 25 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 260 It 305 fL Gray Hard Granite
(If well field,one lattlong is sufficient) 21_REibLARICS
35.194345 N -84.147081 W BIT SIZE 6.04"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 3/15/2023
If this is a repair,fill out known well conshatction information and explain fire nature ofthe Signature ofCertitied lVelI Contractor Date
repair tinder#21 remarks section or on the back ofthis form. By signing thisfoawg I hereby certify that the wellfs)was(were)constructed in accordance
isith IS4 A'CAC 02C.0100 or I5A1VCAC 02C.0200 Fi ell Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple injection or non-water wells ONLF with the saute constructor%you can 23. Site diagram or additional well details:
submit one form. You may use the back ofthis 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
For multiple wells list all depths ifdierent(example-3@ 200'and 2 @ 100) SIIIl''1ITTAL INSTRUCTIONS
10.Static water level below top of casing: 60 00 24a•For All Wells: Submit this form within 30 days of completion of well
If water level is above casing,use" construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (4) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Iniection 1Vells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc-) above,also submit a copy ofthis 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
13a. Yield(gpm): 30 Method of test: Air 24c.For Water Supply Injection Wells: In addtion to sending the form to
the address(es)above,also submit one copy ofthis form within 30 days of
13b. Disinfection type: HTH Amount 12 completion ofwell construction to the county health department ofthe county
where constructed_
Form GIB`-1 North Carolina Department of Environment and Natural Resources -Division of Water Ooalit,- Revised Jan 2013