GW1--03654_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information:
FRONf TO DESCRIPTION
WILLIAM LAWSON
0 ft, 675 ft.
Well Contractor Name 836 ft. 837 tit.
NCWC3491 A I.S.OUTER CASING(for multi-cased wells)OR LINER(lf applicable);
NC Well Contractor Certification Number FRONT TO DIAMETER' THICKNIESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 30 ft' 6.125 'n SDR 212 PVC plastic
Company Name ft- f4 in.
16,INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2023000179 FRONT TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction pertmits(ie County;State,Variance,eta ft ft. in
3.Well Use: ft. ft' in.
11.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. fL in
18.GROUT
FROM TO 'vLATERIAI, ENfPLACEMENTMETHOD&AMOUNT
0 I- ft
concrete 480 - Gravity
ft. ft.
MAY 2 2023 19.SAND/GRAVEL PACK(if applicable)
FRO\d TO MATERIAL ENIPLACIU\MNT METHOD&AMOUNT
fir+ •m
v a a tit. ft. -
4. Date'Well(s)Completed: S/1/2023 Well I1Dt# BIG SKY ESTATES LOT
ft. %
5a. Well Location: 20:DRILLING LOG(attach-additional sheets if necessary) - -
List all applicable well constriction pertmits(ie County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
PREMIER LAND DEVELOPMENT WELL#2 0 ft. 675 ft. DRILLED 8131/05 1 GPM
Facility/Owner Name Facility ID(ifapplicable) 675 ft. 836 ft. Gray Hard Granite
SOUTHMEW TRL MURPHY 28906 Lot a 836 tit. 837 ft. Gray Fractured Granite SMALL FRACTURE 4 GPM
Physical Address,City,and Zip 837% 905 ft. Gray Hard Granite
Cherokee 450313240067000 ft. ft
County Parcel Identification No.(PIN) ft. ft.
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft' fL
(117well field,one latIlong is sufficient.) 21.REIIIARKS
N , W ORIGINAL DEPTH WAS 675'-DRILLED DEEPER FROM 675'TO 905' BIT
IZ 1
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: Noiwozo4l 5/24/2023
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certifie el Contractor Date
repair under#21 remarks section or on the back ofthisform. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 IFell Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis record has been provided to the it-ell owner.
For multiple trjection 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 ofthis page to provide additional well site details or well
construction details. You may also attach additional pages ifnecessary.
9.Total well depth below land surface: 905
For multiple wells list all depths ifdierent(example-3@ 260'and 2 @ 100) SUNEITTAL INSTRUCTIONS
10.Static water level below top of casing: 50 (ft.) 24a.For All Wells: Submit this fonn 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 (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 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): 5 Method of test: Alr 24c.For Water Supply Injection Wells: In addtionto sending the fonn to
the address(es)above,also submit one copy ofthis form,%ithin 30 days of
13b. Disinfection type: HTH Amount: 40 completion of well construction to the county health department ofthe county
where constructed.
I
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013