GW1--03047_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD 1
For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
•OM TO DESCRIPTION
WILLIAM LAWSON 135ft. 136 ft.
Well Contractor Name 168 ft. 169 ft.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR I,l\ER(if applicable) i
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 R 60 ft* 6.125 In- SDR 21 PVC plastic
Compam
y Name ft ft. in. -
16 INNER CASIPIG OR TUBING(geothermal dosed loop) ''.
2.Well Construction Permit#: W2024000001 2022000683 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County,State,Variance,eta ft ft. in.
3.Well Use: ft. ft. in.
17.SCREEN
FROM TO DL\METER THICKNESS ]SLOT SIZE j MATERIAL 1
Residential ft. ' ft is.
ft. ft. in.
1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
rr 1 It t1t
6 t,;_.,�.>i,.� lr' 1...,?,r 0 3 eerrtonite Pelletts 50 Gravity
MAY 2 2024 3 ft• 20 Bentonite slurry 150 Pumped/Tremie
ft.
i9.SAND/GRAVEL PACK(if applicable) lin
lrf3:ar..“:'' ,''-.,.-. 4:kitFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
D �„5
it. ft.
0O 4/17/2024 Well ID#4 Date Well(s)Completed: ft ft.
ft, ft.
Sa. Well Location: D, t r t if nary)
List all applicable well construction pertmits(ie County,State Variance,etc. FROM TO DESCRIPTION(cola,hardness,soil/rock type,grain size,etc)
STEVEN NEAL Oft. 42 ft. Blown Medium Slate
Facility/Owner Name Facility ID(if applicable) 42$. 60 ft. Gray Hard Granite Set Casing
179 FAWN LN MURPHY 28906 Lot 60 ft. 135 ft Gray Hard Granite
Physical Address,City,and Zip 135 ft. 136 ft. Gray Fractured Granite Small Fracture 8 GPM
Cherokee 455200361138000 136ft. 168 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 168 ft. 169 ft. Gray Fractured Grande Large Fracture 17 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 169 ft. 205 ft. Gray Hard Granite
(If well field,one tat/long is sufficient) 21.REMARKS `
35.085662 N -84.173527 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. Certification:7. Is this a repair to an existing well: NO 4/23/2024
If this is a repair,fill out known well construction information and explain the nature of the Sigoattre of Certifi a Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100or 15A 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 (it.)
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.) 240.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
water level is above casing,use"+"
If
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): 25 Method of test: Air 24c.For Water Supply Injection Wells: In addtion to sending the form to
the addresses)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 Ian 2013