GW1--02816_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD 'For Internal Use ONLY:
This form can be used for single or mutiple wells 1
14.WATER ZONES 13
1.Well Contractor Information: .` '
FROM TO DESCRIPTION I
WILLIAM LAWSON 108 ft. 109 IL
Well Contractor Name 161 ft. 163 ft-
II
NCW C3491 A 15.OUTER CASING(for multi-cased wells)OR LINglOdagOgligRZ460,
NC Well Contractor Certification Number FROM TO DIAMETER! THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 fi- 80 fi- 6.125 n'' SDR 21 PVC plastic
Company Name ft. IL in'
16•INNER CASING OR TUBING'(geotherr al closed;loop) _
2.Well Construction Permit#: W2023000673 2021000784 FROM TO DIA,v1ETER 1 THICKNESS MATERIAL
List all applicable well construction pertmits(ie County State,Variance,etc. ft. ft- in. 4
3.Well Use: ft• ft. in.
17:SCREEN:.
FROM TO DIAMETER', THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft.I ft. in. I
IS•GROUT
" �: ,.,,.+"o i; T.'.� FROM TO MATERIAL H EMPLACEMENT METHOD&AMOUNT
�+--t-`�`�.I I� 0 IL - 3 ft"- Bentonite Pelieltts 50 Gravity •
MAY 0 6 2024 3 ft 20 ft' Bentonite slurry 200 Pumped/Tremie
ft. ft.
}�:C ,rt��,),�t 19.SALVO/GRAVELPACK(ifapplicable) -
i,'CJ3 FROM TO MATERIAL I, EMPLACEMENT METHOD&AMOUNT
ft. ft. I
I
4. Date Well(s)Completed: 3/8/2024 Well ID# BEAR PAW LOTS 10& ft..
ft. ft
5a. Well Location: 20.DRILL•ING LOG(attach additional she eta if necessary`)
List all applicable well construction pertmits(ie County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
DAN SILVER
0 ft. 58 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 58 ft. 80 . ft. Gray Hard Granite Set Casing
10 FOREST VIEW LN MURPHY 28906 Lot 108,11 80 ft 108 ft. Gray Hard Granite
Physical Address,City,and Zip 108 ft. 109 ft. Gray Fractured Granite Small Fracture 3 GPM
Cherokee 455408888616000 109 ft. 161 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 161 ft. 163 ft. Gray Fractured Granite Large Fracture 23 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 163 it 205 lI Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.'h21 MARS ;
35.146885 N -84.157347 W BIT SIZE-6.00"
6. Is(are)the walls): Permanent i.
22. Certification •
-
7. Is this a repair to an existing well: No ifl, . f52et� 3/14/2024
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certifi a Contractor Date"(./
repair under#21 remarks section or on the back of this form. - i _-By signing signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15,4 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: 205 (ft-) 1,
For multiple wells list all depths if different(example-3(4)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: 60 (ft) !
construction to the following:
If water level is above casing.use"+" Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 Cm) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method:, Rotary • 24b.For Injection Wells: Iu addtionf 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: I 1
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a. Yield(gpni): 26 Method of test: Air 24c.For Water Supply Injection Wells: In addtiontosending the form to
the address(es)above,also submit one copy1 of this form within 30 days of
13b. Disinfection type: HTH Amount: 100 completion of well construction to the county health department ofthe county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Ouality Revised Jan 2013