GW1--06568_Well Construction - GW1_20231006

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 273 ft. 274 ft.
Well Contractor Name 752 ft. 753 ft. 1
NCWC3491A 15.OUTER CASING(for multi-eased wells)OR LINER(if applicable)_.
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft' 80 ft hi' SDR 21 PVC plastic
Company Name ft' ft' in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 0232 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pert:nits(ie County,State,Variance,eta ft. ft. in.
3.Well Use: ft. ft.
17:SCREEN
FROM TO DIAMETER THICI�IESS SLOT SIZE MATERIAL
Residential ft. ft. • in.
ft ft. in.
18.GROUT -_
-� `"" :v--'t FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
'� ` �+� ' 0 ft. 3 ft' Bentonite Pelletts 50 Gravity
O 'i- 0 6 2023 3 ft. 20 ft. Bentonite slurry 150 Pumped/Tremie
• ft. ft.
1:'''-.,c `z1.7:3 a h y 19.SAND/GRAVEL PACK.(if applicable)
.
i3' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
:d'.:y",
ft. ft.
ft. ft.
4. Date Well(s)Completed: 9/15/2023 Well ID# NANTAHALA RIVER CL
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,soil/rock type,grain size,etc)
MOUNTAIN MODERN DEVELOPMENT CO LL LOT 35D 0 ft. 63 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) •
63 ft. 80 ft. Gray Hard Granite Set Casing
LODGE FORK TR BRYSON CITY 28713 Lot 35D NANTAHALA RIVER CLUB/ROCKLEDG 80 ft. 273 . ft. Gray Hard Granite
Physical Address,City,and Zip - 273 ft. 274 ft. Gray Hard Granite Small Fracture 0.25 GPM
Swain - 663100332789 274 ft. 752 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 752 ft. 753 ft. Gray Hard Granite Small Fracture 0.75 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 753 ft 805 ft Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS. .
35.349496 N -83.585485 W BIT SIZE-5.97"
6. Is(are)the well(s): Permanent
22. Certificati •
7. Is this a repair to an existing well: No 9/20/2023
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 1 SA NCAC 02C.0100 or 1 SANCAC 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: 805 (ft.) 1
For multiple wells list all depths ifdi, erent(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: 300. (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 Injection Wells: In addtion to sending the fonn 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
I
13a. Yield(gpm): 1 Method of test: Air 24c.For Water Supply Iniection Wells: In addtionto 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 Department of Environment and Natural Resources -Division of Water Ouality Revised Ian 2013