GW1--06526_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells I
1.Well Contractor Information: 14.WATER ZONES'.. - ` _. _ . '.:1, _
FROM TO DESCRIPTION
WILLIAM LAWSON 190 tit. 191 ft.
Well Contractor Name 268 ft. 269 ft. I I
NCWC3491A 15.OUTER CASING(for multi=cnsed teas)OR LINER(if applicable) `-
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 B- 120 ft" 6.125 1 in• SDR 21 PVC plastic
Company Name ft. D '' '
16.INNER CASING OR TUBING(geothermal closed loop)' -
2.Well Construction Permit#: W2023000429 2022000666 FROM TO DIAMETER THICK NESS MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft. ft. I' in.
3.Well Use: ft. ft' in.
17SCREEN -FROM TO DIAMEiL1 THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. I in.
ft. ft. kin.
18.GROUT- - . , .
n { }''' .FROM TO-- -- MATERIAL -.EMPLACEMENT METHOD&AMOUNT_
,.,:,, it 1- '" o R- 3 R' Bentonite Pelletts 50# Gravity
1 2023 3 ft 20 ft' Bentonite slurry
ft. ft 200 Pumped/Tremie
0C�
^T.7:4-Ftg;riA 19.SAND/GRAVEL PACK(if applicable) `
x_.71 IG FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
fl. ft.
I
ft. ft. y
4. Date Well(s)Completed: 10/4/2023 Well ID# BOURNE SUB TR 13-A
tt ft. e
5a. Well Location: 20.DR ILLING LOG(attach additional sheets if necessary) `
List all applicable well construction pertmits(ie County,State,Variance.eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
VINKO.DOMAZET LOT 9 0 ft. 102 ft. Red Medium Slate
Facility/Owner Name Facility ID(if applicable) 102 ft. 120 ft. Gray Hard Granite SET 120'CASING
45 SHERRY DR MURPHY 28906 Lot 9 BOURNE SUB 120 ft. 190 ,ft. Gray Hard'Granite
Physical Address,City,and Zip 190 it. 191 ft. Gray Fractured Granite SMALL FISSURE 1 GPM
Cherokee 550103132065000 191 ft. 268 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 268 R. 269 ft. Gray Fractured Granite SMALL FRACTURE 19 GPM
5b. Latitude and Longitude degrees/minntes/seconds or decimal degrees: 269 ft 305 ft Gray Hard Granite
(If well field,one Iat/long is sufficient) 21.REMARKS
35.055541 N -84.010794 W BIT SIZE 6.00" II
6. Is(are)the well(s): Permanent
22. Certification
7. Is this a repair to an existing well: No
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Co ctor 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.
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 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: 305 (ft-) '
For multiple wells list all depths if different(example-3(§200'and 2 @ 100) SUNIITTAL INSTRUCTIONS I. '
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 40 (ft.)
If water level is above casing use"+" construction to the following: i ; .
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Servic a 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 ofthis form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,lUndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a. Yield(gpm): 20 Method of test: Air 24e.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: 12 completion of well construction to the county health department of the county
where constructed. i
Form G1V-1 North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Ian 2013