GW1--04794_Well Construction - GW1_20230721

• WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information:
• FROM TO DESCRIPTION
WILLIAM LAWSON 177 ft. 179 ft.
Well Contractor Name ft. ft. I1
NCWC3491 A 15.OUTER,CASING(for multi-cased d wells)OR LINER(if applicable) -
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 60 ft• 6.125 1 i"• SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit 1/: W2021000064 2021000063 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perimits(ie County,State,Variance,etc. ft, ft, in.
•3.Well Use: ft ft in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft ft. in.
18.GROUT
r'�����® FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTR
ft' 20 ft' Bentonite Pelletts 150 Gravityi
ft. ft. . I
JUL 2 1 2023 ft. ft.
�.. ,. 19.SAND/GRAVEL PACK(ifap`pkcable) •
W on PltctlM11i( FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DWORIOG ft. ft.
ft. ft.
4. Date Well(s)Completed: 6/8/2023 Well ID# TR 548 TARHEEL NOR
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction perimits(ie County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
JUSTIN COKER 0 ft. 47 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 47 ft. 60 ft. Gray Hard Granite Set Casing
181 LAKESHORE DR MURPHY Lot 548 TARHEEL NORTH 60 ft. 177 ft. Gray Hard Granite
Physical Address,City,and Zip 177 ft. 179 ft. Gray Hard Granite Large Fracture 15 GPM
Cherokee 459209071190000 179 ft. 225 ft. Gray Hard Granite •
County Parcel Identification No.(PIN) ft. ft.
5b. Latitude and Longitude degrees/ruinutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 21.RE VLslI2hS _
35.09304 N -84.048687 W BIT SIZE-6.00"
•
6. Is(are)the well(s): Permanent
22. Certificatio .
7. Is this a repair to an existing well: No may - 6/15/2023
If this is a repair•,fill out known well construction information and explain the nature ofthe Signature of Certified Well Contractor Date
repair under#21 remarks section or on the back oftlris form. By signing this form,I hereby cer tsfv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been provided to the well owner
Formultiple injection 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 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: 225 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 1009 SUMTTTAL INSTRUCTIONS
10.Static water level below top of casing: 50 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
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 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 of this 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): 15 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 within 30 days of
13b. Disinfection type: HTH Amount: 100 completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Denartment of Environment and Natural Resources -Division of Water Duality Revised Jan 2013