GW1--03988_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple welts
1.Well Contractor Information: 14.WATER 201\'ES
FROM TO DESCRIPTION
WILLIAM LAWSON 301 ft. 303 fit.
Well Contractor Name 312 ft. 315 ft.
NCWC3491 A 15-OUTER CASING(for multi-caseii wells)OR LINER(if applicable)
NC Well Contractor Certification Number FRONT TO DIAMETER ' THICKNESS IvfATERIAI
CHEROKEE WELL DRILLING 0 fL 85 R- 6.125 rrr' SDR 21 PVC plastic
Company Name ft. & in.
16.INNER CASING OR TUBLVG(geothermal closed loop)
2.Well Construction Permit#: 022-1338 JMB3003 FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction pertmits(ie County,State,Irariance,eta ft. It
3.Well Use: f1. tY in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft fL in.
ft fL fin-
_ 1S GROUT-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT19 „ t! ft, ft
JL'ti 1 2 2Q23 ft.
M
t 19.S I iD/GILAVEL PACK if applicable)
fir" ( .
FROM TO D-LkTERIAL EMPLACE\TENT METHOD&AMOUNT
ft. ft.
4. Date Well(s)Completed: 6/2/2023 Well ID# SOURWOOD MTN fL ft.
f1. ft
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,1'arianc4 eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
JEFFREY RUDGE LOT 119 0 ft 63 fL Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 63 f1. 85 ft. Gray Hard Granite SET 85 CASING
WEST CHERRY RD HAYESVILLE 28904 Lot 119 SOURWOOD MTN 85 ft. 301 fL Gray Hard Granite
Physical Address,City,and zip 301 ft. 303 ft. Gray Fractured Granite LARGE FRACTURE 8 GPM
Clay 554000503558 303 ft. 312 fL Gray Hard Granite
County Parcel Identification No.(PIN) 312 fL 315 fL Gray Fractured Granite LARGE FRACTURE 12 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 315 ft. 365 fL Gray Fractured Granite
(If well held,one lat/long is sufficient.) 21.RET%LtRkS "
35.027486 N -83.860674 W VARIANCE APPROVAL NO.JMB3003-CASING GROUTED ENTIRE LENGTH
5FT-BIT I .1
6. Is(are)the well(s): Permanent
22. Certif'ic. n:
7. Is this a repair to an existing well: No �. 6/8/2023
If this is a repair,fill out known well constrction information and explain the nature ofthe Signature of iFiecIVUellCoptractor Date
repair under#21 remarks section or on the back of thisform. By signing thisform.I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA ArCAC 02C.0100 or 1 SA ArCAC 02C.0200 i3 ell Construction Standards and that a
S. Number of wells constructed: 1 copy ofthis record has been prordded to the well owner.
For multiple injection or non-water wells ONLY with the saute 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 Nvell
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 365 (ft.)
For multiple wells list all depths if different(example-3 a1200'and 2 C 1009 SUN11TTAL INSTRUCTIONS
10.Static water level below top of casing: 100
24a.For All Wells: Submit this form within 30 days of completion of well
(1t.)
construction to the following:
If water level is above casing use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Senice Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Injection Wells: In adi tiori to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy ofthis form-%ithin 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 Senice Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 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 of this form,%ithin 30 days of
13b. Disinfection type: HTH Amount: 12 completion of well construction to the county health department of the county
where constructed.
Foam GW-1 North Carolina Deoartment of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013