GW1--07239_Well Construction - GW1_20231108

r
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells j'
1.Well Contractor Information: 14.WATER ZONES_ kn
FROM TO DESCRIPTION
WILLIAM LAWSON 120 ft. 121 ft.
Well Contractor Name 152 ft 158 ft. I
N CW C3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) ,"
NC Well Contractor Certification Number FROM TO DIAMETER i I THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ff. 60 ft• 6.125 in' I ' SDR 21 PVC plastic
Company Name ft• ft. in. 1
16•INNER CASING OR TUBING(geothermal closed loop) '£ s' n
t��
2.Well Construction Permit#: W202000685 2022000700 FROM TO DIAMETER 1 .THICKNESS MATERIAL
List all applicable well construction pertnrits(ie County,State,Variance,eta ft. ft. in
3.Well Use: ft ft. m I
17.SCREEN
FROM TO DIAMETER ' THICKNESS SLOT SIZE MATERIAL
Residential ft. ft in.
ft. ft. in.
18.GROUT y
I T r FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
i� ' '.-- „.e'--a "m • 0 it 3 it. Bentonite Pellptts 50# Gravity
3 ft- 20 ft- Bentonite slurry 200 Pumped/Tremie
Nov 0 S 2023 ft. ft.
19.SAND/GRAVEL PACK(if applicable) - �`- `'
aim }7r-r-;.,.`?.:''.4 lill . . .�r_A
lni .r.., 1 ' FROM TO MATERIAL I, EMPLACEMENT METHOD&AMOUNT
Civu :i `�'� ft. ft. I
ft. ft.
4. Date Well(s)Completed: 10/5/2023 Well ID#
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)'
List all applicable well construction pertnuts(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
PATRICIA BAILEY 0 ft. 33 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 33 ft 60 ft Gray Hard Granite SET 60'CASING
3685 CANDY MOUNTAIN RD MURPHY 28906 Lot 60 ft. 120 ft. Gray Hard Granite
Physical Address,City,and Zip 120 ft. 121 ft. Gray Fractured Granite SMALL FRACTURE 2 GPM
Cherokee 452300908906000 121 ft. 152 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 152 ft. 158 ft. Gray Fractured Granite FRACTURED ZONE 1,00 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 158 ft. 205 ft Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.094165 N -84.250322 W 5.98" 1
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 10/11/2023
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 thisform By signing this form,•I hereby certfy that the well(s)was(were)constructed in accordance
'with 15A 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.
23
For multiple injection or non-water wells ONLY with the same construction,you can • 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: 205 (ft-) II
For multiple wells list all depths ifdifferent(example-3ig 200'and 2 C 100) SUM1TTAL INSTRUCTIONS f
10.Static water level below top of casing: 60 (ft.)• 24a.For All Wells: Submit this fomi within 30 days of completion of well
If water level is above caring,use"+" construction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 16171bIail Service 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 of t is 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 Mall Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 100 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: 10 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deoartment of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013