GW1--05963_Well Construction - GW1_20230912

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 143ff. 144 ft. I I
Well Contractor Name 347 ft. 348 ft. I i
NCWC3491A 15.OUTER,CASINNG(for multi-cased wells)ORLINER(if applicable); F
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft' 90 it 6.125 in- SDR 21 PVC plastic
ft Company Name ftin '
16.INNER CASING O R TUBING(geothermal dosed loop)
2.Well Construction Permit#: W2023000350 5/18/1982 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc ft- ft. . in.
3.Well Use: ft '
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. 1 hi
tit ft. . in.
18.GROUT
_ 4.-.DFROM TO MATERIALEMPLACEMENT METHOD&AMOUNT
j } t� 0 3 R' Bentonite Pella 50 Gravity
3 ft• 20 ft' Bentonite slurry 100 Pumped/Positive Di
' SEP 1 2 2023 ft. ft.
19.SAND/GRAVEL PACK(if applicable)
(gyp:iFati tC't fir^ liOt
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT •
ft. ft. 1 '
4. Date Well(s)Completed: 6/30/2023 Well ID# DOGWOOD THICKET
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary) _
List all applicable well construction pertnrits(ie County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soilhock type,gain size,etc)
SANDRA BALLARD LOT 10 0 ft. 73 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 73 ft. 90 ft. Gray Hard Granite Set 90'Casing
413 OLD JOHNSON RD MURPHY 28906 Lot 10 DOGWOOD THICKET 90 ft. 143 ft. Gray Hard Granite
Physical Address,City,and Zip 143 ft. 144 ft. Fractured Small Fracture 1 GPM •
Cherokee 456003314871000 144 ft 347 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 347 ft. 348 . ft. Fractured Small Fracture 1 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 348 ft. 505 ft Gray Hard Granite
(If well field,one lat/long is sufficient.) 21'REI LARKS`
35.020354 N -84.134477 «' BIT SIZE-5.97"
6. Is(are)the well(s): Permanent ,
22. Certification: 4/
7. Is this a repair to an existing well: No M / 7/20/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified W Contractor a
repair underfr 21 remarks section or on the back of this fornr By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA ACAC 02C.0100 Or 15ANCAC 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.
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: 505 (ft.) i •
For nmltiple wells list all depths ifdifferent(example-3®200'and 2®100) SUMITTAL INSTRUCTIONS i
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 70 (ft-) i
If water level is above cosine use"+" construction to the following: ,i
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 Injection Wells: In addtion to sending the form to the address in 24a
above,also submit a copyof this form within 30 daysof completion of well
(i.e.auger.rotary,cable,direct push,etc.) P
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): 2 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. 1
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Ouality Revised Jan 2013
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