GW1--07911_Well Construction - GW1_20231208

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WELL CONSTRUCTION RECORD For Internal Use ONLY: )
This form can be used for single or mutiple wells •
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14 WATER ZONES .�;,-
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 378 ft. 379 ft.
Well Contractor Name 457 ft. 458 ft. I '
NCW C3491 A is.OUTER GASING for mnIh-cased wells OR LINER if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER: THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 140 ft. 6.125 in* SDR 21 PVC plastic
Company Name ft• ft. in.
16 INNER CASING OR TUB1i G.(geothermal:closed loop) -_ - -
2.Well Construction Permit#:
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmitr(ie County,State,Variance,etc. ft. ft. '•in.
3.Well Use: ft• ft. : in.
17 S<RI:EiV FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. ;' in.
ft. ft. I in.
28 GROUT .,:; - .. - . >.
• 'T•,a r ' —EMPLACEMENT METHOD&AMOUNT
c..S.: Y '�.—,i. •%.1 a 4 l FROM TO MATTRTaT.
0 ft• 3 ft Bentonite Pell tts 50 Gravity
DEC0 8 2023 3 ft. 20 ft. Bentonite sl 200 Pumped/Tremie
ft. ft.
ln,O1-i':r:?.^.n nr..5:^r'. -3 Uf,'X 197S0D/GRAVEI:;PACK(ifapplicable). _ _
"C a OG FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft: ft
ft. ft. I.
4. Date Well(s)Completed: 11/20/2023 Well ID#
ft. ft. I
5a. Well Location: 20 DR1I;tn LOG(atiach additional sheets if necessary)
List all applicable well construction permrits(ie Count};State,Variance,eta FROM TO DESCRIPTION(color,hardness,soiUrocL type,grain size,etc)
MAN DY SOTOLONGO LOT 4
0 ft: 118 ft. Tan Medium'Slate
Facility/Owner Name Facility ID(if applicable)
118 ft. 140 ft. Gray Hard Slate Set 140'Casing
720 JOHNSON RIDGE BRYSON CITY 28713 Lot 4 140 ft 378 f Gray Hard Slate •
Physical Address,City,and Zip 378 ft. 379 ft. Gray Fractured Slate Small Fracture 3 GPM
Swain 662000718915 379 ft. 457 ft. Gray Hard Slate .
County Parcel Identification No.(PIN) 457 ft. 458 ft. Gray Fractured Slate Small Fracture 1 GPM
5b. Latitude and Longitude degrees/n inutes/seconds or decimal degrees: 458 ft. 605 ft: Gray Hard Slate to
(If well field,one lat/long is sufficient.) 21 RE.LARKS = ? 1
35.317 N -83.601 W BIT SIZE=5.99" 1
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 11/21/2023
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified I.•e Contractor Date
repair under#21 remarks section or on the back ofthisfornr By signing this ferns I hereby certify that the well(s)was(were)constructed in accordance
with 1 SANCAC 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 nndtiple 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 alsoIattach additional pages if necessary.
9.Total well depth below land surface: 605 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS 1 •
10.Static water level below top of casing: 200 (ft)
24a•For All Wells: Submit this form within 30 days of completion of well
Ifwater level is above casing use"+" construction to the following:
Division of Water Q
uality,Information Procession Unit,
11. Borehole diameter: 6 (m) 1617 Mail Service Center,Raleigh,NC-27699-1617
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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,iUndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a. Yield(ggpm): 4 Method of test: Air 24c For Water Supply Injection Wells: In addlionto sending the form to
the address(es)above,also submit one copy of this faun within 30 days of
13b. Disinfection type: HTH Amount: 100 completion of well construction to ie county health department of the county .
where constructed.
Form GW--1 North Carolina Department of Environment and Natural Resources -Division of Water Ouality Revised Jan 2013
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