GW1--01347_Well Construction - GW1_20240304

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 210 ft. 211 ft.
Well Contractor Name 293 ft. 294 ft.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIANtEtit I THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft' 180 ft- 6.125 1 n!• SDR 21 PVC plastic
Company Name ft• ft I n!'
16.INNER CASING OR TUBING(geothermal closed loop) `K=a
2.Well Construction Permit#: W2023000337 20230001000 FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction pertnrits(ie County State,Variance:etc. ft. ft. I,in-
3.Well Use: ft. ft' in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. I in-
ft- ft- 'in.
•
18.GROUT
.� .., FROM TO MATERIAL EMPLACEMENT METHOD&AIVIOLNT
c
'�_L,L,.1 0 ft. 3 ft' Bentonite Pell us
50 Gravity
MAR 2024 3ft 20 ft. Bentonite slu 150 Pumped/Tremie
19.SAND/GRAVEL PACK(if applicable) _
Inform$it�Pr UM FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
ft. ft. 1
ft. ft. 1
4. Date Well(s)Completed: 11/13/2023 Well ID#
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets-if necessary) ' --- -
List all applicable well construction pertmits(ie County,State,Variance,etc.
KENNETH JEWELL FROM TO DESCRIPTION(color;hardness,soil/raek type,grain size,etc)
0 ft. 157 ft. Brown Medium Slate
Facility/Owner Name • Facility ID(if applicable) 157 ft. 180 ft. Gray Hard;Granite Set Casing
245 COLLETT CREEK RD ANDREWS 28901 Lot 180 ft. 210 ft- Gray Hard'Granite
Physical Address,City,and Zip 210 ft. 211 ft. Gray Fractured Granite Small Fracture 2 GPM
Cherokee 556502667316000 211 ft. 293 ft- Gray Hard Granite
County Parcel Identification No.(PIN) 293 ft_ 294 ft. Gray Fractured Granite Small Fracture 5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 294 ft 325 ft Gray Hard Granite
(If well field,one lat/long is sufficient.) ZI.REl71RItS
35.184006 -- N -83.799382 W BIT SIZE-5.00"
6. Is(are)the well(s): Permanent
22. Certif"ication-
7. Is this a repair to an existing well: No fA. 1/14/2023
Ifthis is a repair,fill out known well construction information and explain the nature ofthe Signature ofC,ertitied Lk C actor ate
repair under#21 remarks section or on the back of this form. By signing this fornm,I herebe cer&fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.1NCAC 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 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 neceecary.
9.Total well depth below land surface: 325 (ft-)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 100 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is above casing,use"+" construction to the following
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): 7 Method of test: Air 24c.For Water Supply Injection Wells: In addtion to sending the form to
the addre(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 Emrironment and Natural Resources -Division of Water Oualitv Revised Ian 2013