GW1--00359_Well Construction - GW1_20240112

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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 95 R. 96 ft.
Well Contractor Name 255 ft. 256 ft
NCW C3491 A 15:OUTER CASOTG(for muitr-cased wells)OR LINER(tf aliphcable)`
NC Well Contractor Certification Number FROM TO DLAMETE1 ' THICiCIESS MATERIAL
CfiEROKEE WELL DRILLING 0 ft 40 B' 6.125 i"• SDR 21 PVC plastic '
Company Name ft. ft. In.
16 INNER CASING OR TUBING'(geothermal closed loop)" =
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perlmits(ie County,State,Variance,etc. IL ft. in..
3.Well Use: B' IL in.
17:SCREEN . .�.._..--..�---• --.-��- -
FROM I TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft ) ft. in.
ft. ft. in.
18:GROUT _ :1 Mkt t
.,� _ �� � ;F.;.__;`
_- FROM__ _._TO, MATERIAL, EMPLACEMENT METHOD&AMOUNT
,.-� •+;".'Ai
p 0's'"COft. tit --
?,-,:. ,; -, O 0 3 Bentonite•Pell 50 Gravity
3 ft 20 ft Bentonite slu 200 Pumped/Tremte
JAN 1 % 2024 ft. IL
ig UtS'3Z 19-SAND/,GRAVEL PAC (afiappheable) ._ ._ , ^`
. _. �-' cam_ r
4^1 P�:'.''•`.?�a' FROM TO MATERIAL I' EMPLACEMENT METHOD8cAMOUNT
,TITC, '•''owc,,ISOG ft. ft
4. Date Well(s)Completed: 12/5/2023 Well ID# ft
ft. ft I ,
5a. Well Location: 20.DRILLING'LOG(attach additional'sheets if necessary): '••%
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION ,color hardness,soil/rock( type,grain size,etc)
WCP REAL ESTATE INC 0 ft. 18 ft. Brown Medium Slate .
.Facility/Owner Name Facility ID(if applicable) 18 ft. 40 IL Gray Hard Granite Set 40'Casing
475 SILVERMINE RD BRYSON CITY Lot 40 IL 95 ft. Gray Hard Granite
Physical Address,City,and Zip 95 ft. 96 ft. Gray Fractured Granite Small Fracture 3.5 GPM
Swain 663000041814 96 ft. 255 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 255 IL 256 IL Gray Fractured Granite Small Fracture 3.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 256 ft. 305 ft Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS r, • _
35.324612 N -83.594939 sir BIT SIZE-5.97"
6. Is(are)the well(s): Permanent
22. Certification: p
7. Is this a repair to an existing well: No I 12/12/2023
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 x 21 remarks section or on the back of this form. By signing this fornt,I hereby certify that the well(s)was(were)constructed in accordance
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with 1SANCAC 02C.0100 or 15A NCAC 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 det ails:
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 ifdiferent(example-3(4)200'and 2 @ 100) SUMIT"rAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 50 (f.)
If water level is ab a casing use"+^ construction to the following:
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Division of Water Qaolity,Information Procession Unit,
11. Borehole diameter: 6 (m.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary 24b.For Injection Wells: In addtiori to sending the form to the address in 24a
(to.auger,rotary,cable direct push etc.) above,also submit a copy ofthis 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): 7 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: 100 completion of well construction to the one;
health department of the county
where constructed.
Form GW-1 North Carolina Deoattment of Environment and Natural Resources -Division of Water Duality Revised Jan 2013
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