GW1--01419_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I
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This form can be used for single or mutiple wells
1.Well Contractor Information: 14`,V 1T$R7.oNES_ :u_
FROM I TO DESCRIPTION
WILLIAM LAWSON 112ft. 113 ft.
Well Contractor Name
330 ft. 331 ft.
NCW C3491 A IS:OUTERC1.SIlNG f(fo mr ltt cased wells)_OR LINER(if apphcable)
NC Well Contractor Certification Number FROM TO DIAMETER 1 THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft- 80 f 6.125 I r"• SDR 21 PVC plastic
Company Name ft ft i u1•
16,INNERCASING OR TUBING,(geotliermal closed loop) :
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertrnits(ie County State,Variance,etc. ft. ft. !in.
3.Well Use: ft ft I in.
17.SCREEN << =
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. I;ill-
ft, ft. ihi
- -- 18,GROUT F mo-'
FROM I TO I MATERIAL EIvIPLACEMENT METHOD&AMOUNT
,,.. 0 ft. _ 3 ft Bentonite Pell 50# Gravity
`��'/t
F� 3 f 20 ft- Rent�pit�Sit 200 Pumped/Tremie
ft. ft
MAR 0 1 2024 19.SAND/GRAYIIL PACK(if applicai 1p) _
FROM TO MATERIAL!i EMPLACEMENT METHOD&AMOUNT
mfoneither Prris-airefthti uya ff. ft. I;
p Ci5OG ft. , ft.
4. Date Well(s)Completed: 1/31/2024 Well ID# HICKORY ROCK FALLS
ft ft. I!
5a, Well Location: -
20:DRILLING(attach additional'sheers of necessary) -— :`
List all applicable well construction pertmits(ie County,State,Variance,etc FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ROBERT STEPHAN LOT 30 0 ft. 58 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 58 ft. 80 ft. Gray Hard Granite SET CASING
855 HICKORY ROCK RD BRYSON CITY 28713 Lot 80 ft. 112 ft. Gray Hard Granite
Physical Address,City,and Zip 112 ft. 113 ft. Gray Fractured Granite SMALL FRACTURE 0.5 GPM
Swain 656900167614 113 ft. 330 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 330 ft. 331 ft. Gray Fractured Granite SMALL FRACTURE 3.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 331 ft. 405 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS "',
35.306426 N -83.48784 W BIT SIZE 5.98" II
6. Is(are)the well(s): Permanent
22. Ce ratio "
7. Is this a repair to an existing well: No A.. L 2/21/2024
Ifthis is a repair ill-outknown 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 this form By signing this form,Iherebycertifythatthewell(s)waas(were)constructedinaccordance
with ISA NCAC 02C.0100 or 15,4 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 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: 405 (ft-) i,
For multiple wells list all depths tfdiferent(example-3@ 200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 (ft-) '
Ifwater level is above casing,use"+" construction to the following: !
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (fn) 1617 Mail Service Ceaiter,Raleigh,NC 27699-1617
12..Well construction method: Rotary air 24b,For Injection Wells: In addtioi to sending the form to the address in 24a
(i.e.atuger,rotary cable,direct push etc.) above,also submit a copy of this form within 30 days of completion of weIl
construction to the following: I I
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a: Yield(gpm): 4 Method of test: Air 24c.For Water Snpnly 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: 18 completion of well construction to the county health department of the county
where constructed. i
Form GW-t North Carolina Department of Environment and Natural Resources -Division of Water Odality Revised Ian 2013
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