GW1--05474_Well Construction - GW1_20230821

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fonn can be used for single or mutiple wells
1.Well Contractor Information: 14.WATER ZONES
FROM TO f DESCRIPTION
WILLIAM LAWSON 190 ft- 191 ft.
Well Contractor Name 222 ft- 224 ft.
NCW C3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)` r 4
NC Well Contractor Certification Number FROM TO DIAME1'hR THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 80 ft- 1 6.125 , in- SDR 21 PVC plastic
Company Name ft. m
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2023000340 2023000284 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(le County.State,Variance,etc. ft. ft. ( in.
3.Well Use: ft. ft. in.
17.SCREEN - -
FROM TO DIAMETER THICKNESS SLOT Sr7F MATERIAL
Residential ft. ft. in.
b, F ft. ft. in.
��t � i Cis 18..GROUT , . `x. . _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
AUG 2 I. 2023 0 ft' 20 ft. Rentoniteie tts 200 Gravity
j;{4 ft. ft.
p.m,somigminkf ff tiC'n• ft. ft.
•
19.SAND/GRAVEL PACK(if applicable) -- _ -
•
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft. I
ft. ft.
4. Date Well(s)Completed: 6/15/2023 Well ID# TARHEEL NORTH
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State.Variance,etc FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etch
HEATHER NORTON/CHRIS JOHNSTON TRACT 551 0 ft. 63 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 63 ft. 80 ft. I Gray Hard Granite Set 80'Casing
LAKESHORE DR MURPHY 28906 Lot 80 ft 190 ft. Gray Hard Granite
Physical Address,City,and Zip 190 ft. 191 ft Gray Hard Granite Small Fracture 5 GPM
Cherokee 458212970264000 191 ft. 222 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 222 ft. 224 ft. Gray Hard Granite Large Fracture 55 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
224 ft. 245 ft. I Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.094031 N -134.053351 W BIT SIZE-5.97"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 6/20/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified I.'ell Contractor Date
repair render#21 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has been provided to the 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 fort:. 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: 245 (ft-)
For nndfiple wells list all depths ifdiljerent(example-3L 200'and 2 @ 100) SU&IITTAL INSTRUCTIONS
10.Static water level below top of casing:
80 (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 24b.For Infection 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): 60 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.
Form GW-1 North Carolina Deoartment of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013