GW1--02594_Well Construction - GW1_20240426

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14:%%ATER ZONES r uAA4
1.Well Contractor Information: FROM TO DESCRIPTION
WILLIAM LAWSON
662 ft. 663 ft.
Well Contractor Name
ft. ft
N CWC3491 A 15.OUTER CASING(for.multi-cased wells),OR LINER(if'il phcabie)
NC Well Contractor Certification Number FROM TO DIAMEthR, TFIICITIESS MATERIAL
CHEROKEE WELL DRILLING 0 ft• 30 ft 6.125 hn• SDR 21 PVC plastic
Company Name ft- ft• j in.
16 INN_E_R CASIIYG_ORTUBIN'Crt(geothcmnal closed(ioop) & mom
2.Well Construction Permit#: 022-1436 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!-
_ � �
17'SCREEN i r � = .' j-:�
FROM TO DIAMETER' THICITIESS SLOT SiZP MATERIAL
Residential ft. ft. I'in.
ft ft !in.
18 GROUT - ` 7- ,
-
FROM. TO -. MATERIAL EMPLACEMENT METHOD&AMOUNT_
tp I`,;.;f"%F: � , ft. ft
N,L..,%,,1.t 1. 1•,s.� 0 3 Benton' Pell its 50
ft ft
- APR 2 6 20Z4 ft. ft.
19 Sc111TD/GRAVELI PACIZ(rf applicable ° t.-9:;riat"-s
li 0M-4ri.ci i s P';rr`441=.5 ligli FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
DV W30G fl;_ ft.
ft. ft,
4. Date Well(s)Completed: 3/4/2024 Well ID#
ft. ft.
5a. Well Location: 20y DRIliI ING LOG(attach 4ddrhoiral sheets rf necessary) _ .; swat,
List all applicable well construction pertmits(ie County,State.Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
CARLO SCIANDRA 0 ft 8 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 8 ft. 30 ft. Gray Hard Granite Set Casing
416 SCENIC DR HAYESVILLE 28904 Lot 25 3D ft. 662 ft. Gray Hard Granite
Physical Address,City,and Zip 662 ft. 663 ft. Gray Fractured Granite Small Frature 0.05 GPM
Clay 553100143668 663 ft. 705 ft. Gray Hard Granite
County Parcel Identification No.(PIN) ft ft.
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft
(If well field,one lat/long is sufficient) 21 REMAI CS
35.064474 N -83.91087 W BIT SIZE-5,56"
6. Is(are)the well(s): Permanent
22. Certification: i
7. Is this a repair to an existing well: No 3/7/2024
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#2I remarks section or on the back of this fonn By signing thisform,I hereby certify that the ice11(s)iva"s(Were)constructed in aCeordafice
with 1 SA NCAC 02C.0100 or I SANC.4C 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: 705 (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:
400 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Ifwater level is above casing,use"+"
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 air 24b.For Infection Wells: In addtionytasending 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,Unde rgroun Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
13a. Yield(gpm): 0.05 Method of test: Air 24c.For Water Supply Injection Wells: In addtion to sending the fore 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 county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013