GW1--06403_Well Construction - GW1_20231009

WELL CONSTRUCTION RECORD • For Internal Use ONLY: i
This form can be used for single or mutiple wells I
14.WATER ZONES •
1.Well Contractor Information: • FROM TO DESCRIPTION
WILLIAM LAWSON. 632 ft. 633 ft. I i
Well Contractor Name 732 ft. 733 ft. ; ' •
NCWC3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO ' DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 40 ft. 6.1251 in. SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 7/12/22 R JENKINS FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County;State,Variance,etc. ft. ft. in.
3.Well Use: ft. ft. •. in.
17.SCREEN
FROM ' TO DIAMETER THICKNESS SLOT SIZ MATERIAL
Residential ft. • ft. in.
ft. ft. in.
-.�,- �,+ 18.GROUT ,- - -
,v�'� -4,..C...1.•, `i tl-�.'} FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT '
0 ft. 3 ft• Bentonite Pelletts 50# Gravity
OCT 0 9 2023 3 ft. 20ft• Bentoniteslutgy 150 Pitmped/Tremie
ft. ft.
Ifl‘:,o Yi:.i`;1 o,,r.-"`""•l�'7 lira 19.SAND/GRAVEL PACK(if applicable)
(✓'at.Y'�-3 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 8/22/2023 Well ID# GLORY MTh ft. ft
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,etc)
PATRICIA J LUMPKIN LOT 21 0 ft. 7 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 7 ft. 40 ft. Gray Hard Granite SET 40'CASING
792 GROUSE DR BRYSON CITY 28713 Lot 21 GLORY MTN 40 ft. 632 ft. Gray Hard Granite •
Physical Address,City,and Zip 632 ft. 633 ft. Gray Granite SMALL FRACTURE 0.5 GPM
Swain 664000192749 633 ft. 732 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 732 ft. 733 ft. Gray Granite SMALL FRACTURE 0.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 733 ft. 805 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) • 21.REMARKS i
35.339605 N -83.557367 w • BIT SIZE 5.87"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 8/27/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Contractor Date
repair under#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 15A 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.
Fornmhiple 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: 805 •
(ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS •
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 200 (ft.)
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 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 I 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 24c.For Water Supply Infection 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: 27 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 Oualitv Revised Jan 2013
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