GW1--06660_Well Construction - GW1_20231006

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or mutiple wells ,
1.Well Contractor Information: 14.WATER ZONES ,
FROM TO DESCRIPTION
WILLIAM LAWSON 59 ft. 60 ft. I
Well Contractor Name ft. ft.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) 1
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 30 ft 6.125 1° SDR 21 PVC plastic
Company Name ft. ft. 1 in.
16.INNER CASING OR TUBING.(geothermal closed loop) j
2.Well Construction Permit#: W2023000348 FROM TO - 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 j
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT
_ _ _ .. i..7
„ vr �s FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_.. .
�� 0 ft 3 ft. Grant'tar bentonite/ 50 Gravity
O C T 0 b 2023 3 ft. 20 ft• Bentonite Pelletts 150 Pumped/Tremie
ft. ft.
s.,. t+'i^.�P'• �' t"'3 t"' 19.SAND/GRAVEL PACK(if applicable) j
l ''+' :� FROM TO MATERIAL EMPLACEMENT METHOD&AMOIIN
ft. ft. ,
ft. ft.
4. Date Well(s)Completed: 9/27/2023 Well ID#
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary). • j
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardnes,soil/rock type,grain size,etc)
RABY CARTER 0 ft. 14 ft. Tan Medium Slate'
Facility/Owner Name Facility ID(if applicable) 14 ft. 30 ,ft. Gray Hard Granite Set Casing
119 CARTER RD MURPHY 28906 Lot • 30 ft. 59 ft. Gray Hard Granite
Physical Address,City,and Zip 59 ft. 60 ft. •Gray Hard Granite Small Fracture 3 GPM
Cherokee 458400593312000 60 ft. 405 • ft. Gray Hard Granite
County Parcel Identification No.(PIN) ft. ft
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft. •
(If well field,one lat/long is sufficient.) 21.REMARKS 1
35.152808 N -84.069461 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 9/28/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Contractor Date
repair under it 21 remarks section or on the back of this form. By signing this form,I hereby certt&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
S. 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: 405 (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: 20 (ft.)
construction to the following:
Ifwater 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 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.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): 3 Method of test: Air 24c.For Water Supply lniection 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 Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013