GW1--04964_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information: 14 WATER ZONES _$
FROM TO DESCRIPTION
WILLIAM LAWSON 237 ft. 238 ft.
Well Contractor Name 438 ft 439 ft. I I
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N CWC3491 A 15.OUTER CASING(for multi',cased wells)OR L NER(if ippticable) - ,_.
NC Well Contractor Certification Number FROM TO I DIAMETER; THICKNESS MATERIAL
CHEROKEE WELL DRILLING • 0 IL 55 ft- . 6.125 ' in- SDR 21 PVC plastic
Company Name ft- ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000689 8/17/01 FROM TO DIAMETER THICIG\IESS MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,eta ft. ft. in.
3.Well Use: ft. ft. in.
SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft ft. in.
ft. ft. in.
a r+ ;7:P!e: C 18.GROUT.. ,`
la 1 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
AU G 0 7 2023 0 ft. 20 ft Bentonite Pell tts 150 Gravity
ft. ft.
7r,r;•.q^,.::Ar lyr'i ft ft.
IP>N li ti2, `-) 19.SAND/GRAVEL PACK if a pl.c..ble "-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
ft. ft.
4. Date Well(s)Completed: 4/25/2023 Well ID# WOLF KNOB EST PH 1
ft ft
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,eta FROM TO' ' DESCRIPTION color,hardness,soilfroct
JAMES BOYETT/CHRISTINE BONO LOT 10 Oft '37 ft. Tan Medium Slate( �ee.grain sr�,etc)
Facility/Owner Name Facility ID(if applicable) - 37 ft 55 fL Gray Hard Granite Set Casing - '•
195 GREY WOLF LN MURPHY 28906 Lot 10 WOLF KNOB ESTATES 55 ft. 237 ft. Gray Hard Granite
Physical Address,City,and Zip 237 ft. 238 ft. Gray Fractured Granite Small Fracture 0.5 GPM
Cherokee 457500264021000 238 ft. 438 ft. Gray Hard Granite
county Parcel Identification No.(PIN) 438 ft. 439 .ft. Gray Fractured Granite Small Fracture 0.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 439 ft. 605 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.RE11 IRKS ' _
35.169117 N -84.113964 W BIT SIZE-5.97"
6. Is(are)the well(s): Permanent
22. Certificatio .
7. Is this a repair to an existing well: No If 4/27/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Tell Contractor Date
repair under421 remarkssectionoronthebackofthisform. -
By signing this fonn,I hereby certi that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1. copy of this record has been provided todhe well owner.
For multiple 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 ofthis 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: 605 (ft-)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUA'IITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 (ft.)
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 24b.For In jection 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 forth 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): 1 Method of test: Air I 24c.For Water Supph 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 Amomrt: 100 completion of well construction to the county health department of the county
where constructed. 1 ,
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan 2013
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