GW1-2023-02786_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For Internal Use O\TLY:
This form can be used for single or mutiple wells i
1.Well Contractor Information: 14.1VATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 184ft_ 185 ft.
Well Contractor Name 221 ft 222 ft
NCWC3491 A 1a.OUTER CASENG' (pnr mt lti-cased weI15)OR LlIvER(mf aPpli. bl
NC Well Contractor Certification Number FROM TO DIAMETER THICK—NESS IvL4TFRIAT.
CHEROKEE WELL DRILLING 0 ft. 90 ft. 6.125 I inm' SDR 21 PVC plastic
Company Name ft. ft. in..
16 INI\1 RC.tiSIti 0RTLI3IN (;etltherm3lcloficdloop)
2.1Vell Construction.Permit#: W2023000081 W2021000267 FROM TO DL4METER THICKNESS LCATERL4i
List all applicable well construction pertmits(ie Caunq;State,Variance,eta ft M in.
3.Well Use: % ft. in.
FROM TO DLAMETER TMCKNESS SLOT SIZE MATERLAL
Residential ft. ft in.
ft ft
18.GROUT
FROM TO AQATEIt1AL. Mi BILACI Z,IFNT,,I.THODa.'�,',IOUNT
ft. ft. Rentonite
APR 1 ; 2023
�_�..?, ;;'.• l.nt FROM _ TO MATERIAL E1�iPLACF�UIENT METHOD&AMOUNT
•i• ... _ ft. ft.
.Jsul},Jv
ft. ft.
4. Date NVell(s)Completed: 3/31/2023-Well ID# INDIAN ROCK SPRGSt
ft. ft.
5a. 1Vell Location: -0-DRI1.I_._LN'G LOG(attach adAMo-ialsbee is ifImecessarv)
List all applicable well construction pertmits(ie County,State,Viriance,etc. FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc)
JUDY NEWTON SEC 5 0 ft. 67 ft Brovrn Medium Slate
Facility/OvmerName Facility ID(if applicable) 67 ft. 90 ft Gray Hard Granite Set Casing
22 KITTUWAH TRL MURPW28906 Lot34 INDIAN.ROCK SPRINGS 90 ft. 184 ft. Gray Hard Granite
Physical Address,City,and Zip 184 ft. 185 ft. Gray Fractured Granite Large Fracture 26 GPM
Cherokee 453100417627000 185 M 221 ft. Gray Hard Granite
County- Parcel Identification No.(PIN) 221 ft. 222 ft. Gray Fractured Granite Small Fracture 8 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 222 ft 225 ft. Gray Hard Granite
(If well field,one Iat/long is sufficient,)
35.042816 N -84.231738 W BIT SIZE-6.01"
6. Is(are)the well(s): Permanent
22. Cet'tification:-
7. Is this a repair to an existing well: No _ 4/3/2023
If this is a repair,fill out known well consO uction information and exph7in the nature ofthe Sigitature ofCerdfied 4t e I ontrachsr Date
repair finder"21 remarks section or off the back ofthisfo77n.
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 AICAC 02C.0100 or 15R NCAC 02C.020011 e11 Construction Standcirds and chat a
S. Number of-sells constructed: 1 copy ofthis record has been provided to the well owner.
For multiple injection or non-water wells ONLPwith the safe construction,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 vvell
construction details. You may also attach additional pages ifnecessary.
9.Total well depth below land surface: 225 (ft.)
For nmftiple wells list all depths if different(example-3®200'and 2 L 100') SUAIITT.AL EVSTRUCTIOi\TS
24a.For All Wells: Submit this form vv'ithin 30 days of eompletion.of well__
10.Stafic water level below top of casing: 60 (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 24b.For-Injection Wells: - In addtion to sending the fora to the address in 24a
(i.e.auger,rotary;cable,direct push,etc.) above,also submit a copy ofthis form within 30 days ofcompletion ofw•ell
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 ALtil Service Center,Raleigh,NC,27699-1636
13a. field(,-pm): 34 Alethod of test: Air 24c.For Water Supply Iniection Wells: In addtion to sending the fotnm to
the address(es)above,also submit one copy ofthis form within 30 days of
13b. Disinfection hype: HTH -Amount: 100 completion of well construction to the county health department of the county
where constructed.
Form GLI=1 North Carolina Department of Environment and Natural Resources -Division of Water Oualita Revised Tan 2013