GW1--04663_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 123 ft. 124 ft.
Well Contractor Name 182 ft. 183 ft
NCWC3491 A 15.OUTER CASING(fbr mufti-cased wells)OR LINER(if appBcable)
NC Well Contractor Certification Number FROM T TO DIAMETER THICKNESS ' MATERIAL
CHEROKEE WELL DRILLING 0 ft 114fi- 6.125 h' SDR 21 PVC plastic
Company Name It. ft. in
A
16,INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2022000674 2022000166 FROM TO I DIAMETER THICKNESS i MATERIAL
List all applicable well construction pertntits lie County,State.Variance,eta ft. ft ! in.
3.WeD Use:
ft. ft. ! in.
17.SCREEN
FROM TO DIAME I ER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft in.
ft ft. is
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft 3 ft Bentonite Pellet's 50 Gravity
3 ft 20 ft* Bentonite slum 150 Pum remie
�' �.:.7; / '"� ft. ft.
y .: (,.r l... �! U 19.SAND/GRAVEL PACK(if applicable)
I ^'I G Z024 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft.
4. Date Well(s)Completed: 7/22/ n,,r a' , i r1.)/PA it
(YNC/304i ft. n.
Sa. Well Location: MELLING additional sheets if necessary)
List all applicable well construction pertmits(ie County.State.Variance,etc. FROM 1 TO DESCRIPTION(color,hardness,soil.rock type,gain size,etc)
LARRY FRENETEE
0 ft. 92 ft Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 92 ft. 114 ft Gray Hard Granite Set Casing
1271 DOVE HOIW MURPHY 28906 Lot 114ft. 123 ft Gray Hard Granite
Physical Address,City,and zip 123 ft 124 ft Gray Fractured Granite Small Fracture 1 GPM
Cherokee 454400021797000 124 ft. 182 ft Gray Hard Granite
County Parcel Identification No.(PIN) 182 ft. 183 ft Gray Fractured Granite Large Fracture 24 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 183 ft 225 ft ; Gray Hard Granite
(If well field,one latlong is sufficient) 21.REMARKS
35.128649 N -84.219629 W ' BIT SIZE-5.96"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: NO //j//z 7/23/2024 If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified 'e I Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the xr0(s)was(were)constructed in accordance
with 1 SA 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 time 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: 225 (f.)
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-) 24e.For AB Wells,: Submit this form within 30 days of completion of well
conslniction to the following:
If water level is above casing use"+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (hi.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary 24b.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 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 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 Ian 2013