GW1--03774_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
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1.Well Contractor Information: tQTO�� DESCRIP7TON
WILLIAM LAWSON ! iL ft.
Nell Contractor Name
NCWC3491A 1�gyI?TFIt£ I�FO(lnFamualti easedeeelLs)r13RIA� (tlF�pplse:tbla,
NC Well Contractor Certification Number FROM TO DIANF-TER ry -TRICK.ATESS MATERIAL
CHEROKEE WELL DRILLING 0 fi- i 45 ft- 6.125 in' SDR 21 1 PVC plastic
Company Name Sl- R' m {
`I,OiddFRGs'i OId I'irR YG(geotheF-F—closed lo op)• r
IWell Construction Permit#: W202-2000598 W2022000597 rROkf 'T—T O—� DIAMETER TfUC:IUNESS-- X[ATERIAL ~+
List all applicable well constriction perUnits f'fe Coutrg:State,l•cuiance,eta ft. t. I ; im.1
3.11'ell Use: B ft. J.
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.-
FROIA± TO DIAMETER 1 T11100 ESSMI SLOT SIZE INVWERIA1,
Residential fL ff.
FROM. TO 1 '%ir1TERIAZ AlkfoUNT
ft ft.
�^t g-fL q, pft.
y�v� �$•.,�y� rr T .., 'U t i.5 a�'+.��xR--
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FROi4f TO NIATERLAL Em PLACE1tJF.m I\fEmm&.4mo APf
L t fit. ft. I i
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4. Date Well(s)ell(s)Completed: 5/5/2023 Well IIl# fL
5a. Well Location:
2t)DRtLF FiEeG,�� ttttricie aFonal sheets If necarc -
List all applicable well constntction permits(ie Coun%State,Yana=eta pRCQM 4 TO DF.SCRIMON(color,hardness,soi}frocl,type,gain size,etc)
MARTIN VILIMEK OR. 23 ft. Red Medium Slate
FacilitylownerName Facility ID(ifapplicable) 2311. 45 ft Gray Hard Granite SET CASING
168 WOLF CREEK ANNEX RD MURPHY 28906 Lot 45 fit 1705 ft. Gray Hard Granite
Physical Address,City,and Zip ft. ft
Cherokee 441 9001 54921 000 ft. ft
County Parcel Identification No.(PINS ft. % +
5b. Latitude and Longitude degrees/minutes/seconds or decinuti degrees: R' ft t
(Ifwell field,one lablorgissufficient) 21 LtiRK c ' f fir' r '"+ Ta o q r hit
34.995882 N -84.306777 W
BIT SIZE 5.82"
6. Is(are)the well(s): Pennanent
22. CertiFication: ""O���7. Is this a repair to an existing well: No5/912023
Ifthis is a repair;fill out know»well constriction itrforn;ation and erplain the nature ofthe Sign,u re of Certified t'rell Contractor Date
repair.under`i21 remarkssecrionor•on the back ofthisformr si rid: thus o
g3, Rr g ;.f.true,Iluxebv;oemfj tlrat;Yhe xrR/sj,uus(u�ej:[wns7nicterl ir:a�ordani�i
with 15.4 NCAC 02C.fl100 or 15.41YCdC 02C.0200I 4116 Slatttlardi and that a'
S. Number of we1Fs constructed: 1 copy of tins record has been p)mided to the well otnter.
Fornnitiple injection or non-water wells ONLI'with the sane consmtction•you can 23. Site diagram or additionalwell detaiis:
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: 705 (It.)
For multiple wells list all depths ifdiljerent(eraniple-3@ 200'and 2 @ 1007 SUNYITTAL INSTRUCTIONS
24a.For Ail Wells: Submitthis fort within 30 days of completion of"vell
10.Static Rater level below top of casing: 500 (ft.)
If v,•ater losel is abate casing use"+" Construction to ore following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 On.) 1617 Mail Service Center,Raleigh,INC 27699-1617
12. li eR construction method: Rotary air 24b.For Iniection'Wells: In addtion to sending the form to the address in 24a
(i.e.anger,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"YELLS ONLY: Division of"Water Quality,Undergroun Injection Control Program,
1636!fait Service'Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 0 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: 100 completion ofweU construction to the county health department ofthe county
where constructed
Form GlV-1 NerHr C.uolitw Demrtment of Environment and NTahtrdl Resources -Division of 1.ater Quality Revised Jan 2013

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CHEROKEE COUNTY HEALTH DEPARTMENT -pate,
228 Hfiton Street*Murphy,NC 28906*(828)8353853 A.Ce; '9%atq
PRIVATE DRINIUNG WATER WELL
CONSTRUCTION AUTHORIZATION,
Martin Vilimek W2022000598 ' 2022000597
• New,Single Family 441900154921000 10.53
' 1694 Wolf Creek Road
• 64 W L Wolf Cmek Road to 1694
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules
Maintain minimum setbacks,as applicable
'v
E jagram(Not tv°Sc61
f
30' Well Area
50, ' pq
50+ pioposed � Dive Access Road
3BR House .^s..r... ? "
. .Ma•1..VY�4 Y!j~
-f•.YV.I�TWYII�+C �\A
13"Scaaed Poplar Wa CircQ z f
M YL•Y
i[��r �uv'rtet'S
32.4° 3tTg'25°J°Rerl 15,
�90
__ L�rd Vic. l,Jird;�r.Ji
50'_i-
reek
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This permit is valid for a period Of five years except 11hat it may be revoked at any time If ft is determined lot there has been a mateciatdmige rn any fact or 1
cirournstancie upen which the permit is issued. Well location.installation,and protection must meet state regrr3au409s.The wen shall be Inspected and approved by Cherokee
County Health Department betora it Is put Into use. The location of the well indicated by CCHD Is lo provide protection from pnsslbie sources or contamination. FI°w vchnne(well
yield)Is NOT guaranteed at any site by CCHD. R
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE THE WELL IS PLACED INTO SERVICE. PLEASE I
SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?(828)8354853
Issue Date; 09/23/2022 Trevor Peterson,REHS 2143 Authadzed Slate Agent
Date. Owner/Agent SVMfur+e
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