GW1--00316_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells f
1.Well Contractor Information: 14.WATER ZONES _..„.._.1....:„,,
FROM TO DESCRIPTION
WILLIAM LAWSON 215 i1t 216 ft. i
Well Contractor Name 242 ft. 245 ft. j
N CW C3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) _ _
NC Well Contractor Certification Number FROM TO DIAMETER I THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 140 if- 6.125 n'• SDR 21 PVC plastic
Company Name ft ( ft. in.
' 16.INNER CASING OR TUBING:(geothermal closed.loop)," - t •
2.Well Construction Permit#: - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,etc. ft. ft. ! in.
3.Well Use: ft' ft' I in.
1'7.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft • in.
ft- I ft. in-J I
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
t +"'i°VP D 0 ft" 3 Bentonite Pell tts 100 Gravity
i,R .®�*c �.• 3 ft' 20 ft* Bentonite slu 200 Pumped(Tremie
JAN 1 2 2024 ft. ft
19.SAND/GRAVEL PACK(ifapplicable) •- --- : ,- - -----.:
r,,,r,..a .g Ufa FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
intor•:f,k3 t r ...� ft. ft.
i ft. ft. '
4. Date Well(s)Completed: 11/28/2023 Well ID#
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie Country State,Variance,eta FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc)
CHRISTOPHER BOBO. 0 ft. 110 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 110 ft. 140 ft. Gray Hard Granite SET 140'CASING
228 HOWARD EDWARDS RD ROBBINSVILLE 28771 Lot 8 140 ft. 215 ft. Gray Hard Granite
Physical Address,City,and Zip 215 ft. 216 it. Fractured; SMALL FRACTURE 20 GPM
Graham 5694643318 216 ft. 242, ft. Gray Hard;Granite.
County Parcel Identification No.(PIN) 242 ft. 245 ft. Fractured i. LARGE FRACTURE 40 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 245 ft. 305 ft. Gray Hard Granite
(If well field,one latllong is sufficient) 21.REMARKS .-
35.428859 N -83.713726 IV err SIZE 5.97"
..,.....)
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No 12/1/2023
If this is a repair:fill out known well construction information and explain the nature of the Signature of Certifie 11 Contractor Date
repair under#21 remarks section or on the back of this forra. - By signing-this form,I hereby certi'that the well(s)was(were)constructed in accordance-
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy ofthis 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 ofthis 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(a?100') SUMITTAL INSTRUCTIONS 1
24a.For AU Wells: Submit this form within 30 days of completion of well
10.Static water level below top of easing: 80 (ft.)
If water level is above caring use"+" construction to the following:Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (m.) 1617 Mail 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 this fonn 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): 60 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 12 completion of well construction to the county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Ou ality Revised Jan 2013