GW1--04661_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14.WATER ZONES
1.Well Contractor Information:
FROM TO - DESCRIPTION
WILLIAM LAWSON
89 tl. 90 ft
Well Contractor Name 147 ft. 148 fL
NCWC3491 A 15.OUTER CASING(for multi-cased wells)OR LINER(ifapp&cabie)
NC Well Contractor Certification Number FROM TO DIAMETER ' THICKNESS MATERI.L
CHEROKEE WELL DRILLING 0 ft* 70ft. 6.125 hi' SDR 21 PVC plastic
Company Name ft. ft in
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 022-1363 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertnrits(ie County,State,Variance,eta ft. ft, in.
3.Well Use: ft. ft. in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft in.
ff. ft. in.
18 GROUT
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Fr ���...-- ..:it-
..... ,.,` 1 D O ft. 3 ft• Bentonite Pelletts 50 Gravity
3 ft. 20 ft. Bentonite slurry 200 Pumped/Tremie
AUG 0 5 2024 ft. ft.
P.SANDIdRAVRL PACK(if applictee)
3-r r ::,'t t jat
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DrAtCit t_.ci ft. ft.
ft. IL
-
4. Date Well(s)Completed: 6/3/2024 Well'DO HI.ISSELTON PROP
ft. , ft.
Sa Well Location: 20.DRILLING 111001Sch additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,etc FROM ' TO ' DESCRIPTION c color,hardness.soil.rock type,gram size,etc)
TIGHE WHITE LOT 3
Oft. 47 1f. Broom Medium Slate
Facility/Owner Name Facility ro(if applicable) 47 ft. 70 ft Gray Hard Granite Set Casing
1100 WINCHESTER COVE RD HAYESVILLE 28904 Lot 70 ft. 89 ft. Gray Hard Granite
Physical Address,City,and Zip 89 ft. 90 ft. Gray Fractured Granite Small Fracture 10 GPM
aay 557100030809 90ft 147 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 147 ft. 148 ft Gray Fractured Grante Small Fracture 2 GPM
3b. Latitude and Longitude degrees/minutes/seconds or dechnal degrees: 14811f. 205 ft Gray Hard Granite
(If well field,one lat/long is sufficient) y 1.REMARKS
35.067674 N -83.780778 w F BIT SIZE-5.97"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No ,�/i 6/4/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified `ell Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I S.4 NCAC 02C.0100 or 1 SA 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 (IL)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 30 (ft) 24a.For AB Wells: Submit this formwithin 30 days of completion of well
construction to the following:
If water 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 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,Undergrowi Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(glue): 12 Method of test: Air 24c.For Water Supply 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: 100 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources - Division of Water Oualitv Revised Jan 2013