GW1--02729_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be tised for single or mutiple wells i , "
14.WATER ZONES :_
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON ft- ft. 1 1
Well Contractor Name ft- f.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR LINER(tfapplicable)
NC Well Contractor Certification Number FROM TO DIAMETER' THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 R' 25 R• 6.125 rn- SDR 21 PVC plastic
Company Nameft R in'
16.INNER-CASING OR TUBING(geotltermaI:closed loop) `_i;'4,`. _ y,
2.Well Construction Permit#: 0487 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County;State,Variance,etc. ft. ft. : in.
3.Well Use: R ft
17.SCREEN v
FROM TO DIAMETER' THICI&IESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. ! iit.
f.; y 18.GROUT -
' ''{ FROM TO :MATERIAL EMPLACEMENT METHOD&AMOUNT
'
MAY U LGC4 0 3 Bentonite Pell tis l50 Gravity
3ft 20 Bentonite si 150 Pumped/Tremie
1 ft. ft.
!R•`s::F^r z i. . ,s 19.SAND/GRAVELTACK(if applicable);;- .:
Dci,iC u
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft. ,
ft. ft. j I
4. Date Well(s)Completed: 4/3/2024 Well ID# BARTLETT GLEN COVE
ft. ft. I'
Sa. Well Location: 20.DRILLING'LOG(attach additional sheets if necessary);
List all applicable well construction pertnrits(ie County,State,Variance etc FROM TO' DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
MICHAEL BAKER LOT 43 0 ft. 2 ' ft. Brown Soft Slate
Facility/Owner Name Facility ID(if applicable) 2 ft. 25 ft. Gray Hard Granite Set Casing .
796 HIGH MOUNTAIN VIEW RD BRYSON CITY 28713 Lot 43 25 ft. 238 ft. Gray Hard Granite
Physical Address,City,and Zip 238 ft. 239 ft. Gray Fractured Granite Small Fracture
Swain 667102590731 239 ft. 600 , if. Gray Hard Granite
County Parcel Identification No.(PIN) 600 ft. 800 ft. Gray Hard Granite
005 ft. Gray Hard Granite1
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 800 ft.1005
(If well field,one lat/long is sufficient.)
35.370838 N -83.4456'91 W RECOMMEND HYDRO-FRACTURING WELL
6. Is(are)the well(s): Permanent
22. Certifica i : ''
7. Is this a repair to an existing well: No /yy
4/10/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of - ed Well Contractor Date
repair under#21 remarks section or on the back ofthi this By signing this form I hereby certify 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 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: 1005 (ft-)
For multiple wells list all depths if different(example-3®200'and 2®100') SUMITTAL INSTRUCTIONS'
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 1000 (ft.)
Ifwater level is above casing.use"+" construction to the following: i
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
t
12. Well construction method: Rotary air 24h.For Infection 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 foIrrri within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Qaaift 1 Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
•13a. Yield(gpm): 0 Method of test: Air 24c.For Water Supply Iniection 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 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
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