GW1--04659_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or mutiple wells
1.Well Contractor Information: 14 WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON ft ft
Well Contractor Name ft. ft.
NCWC3491A 15.OUTER CASING(for multi-eased wel s)ORLINER(ifanalogic)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft30ff 6.125 h' SDDR 21 PVC plastic
Company Name ft ft' in , i
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 022 12393 FROM I TO \\IF1:R —THIC
KNESS MATERIAL I--.
List all applicable well construction permits(le County,State,Variance,etc ft. ft. in.
3.Well Use:
fl ft. in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ff. ft. in.
i
1&GROUT
't.,g D FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft' 3 ft. Bentonite Peilt�tts 50# Gravity
AUG 0 9 2024 3 ft 20ft Berrtonite sly 150 Pumped/Tremie
ft. ft.
i:: i r.� 1 19.SAND/GRAVEL PACK(if applicable)
lair:..kD C,1 LICE
FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
ft. ff.
4. Date Well(s)Completed: 6/20/2024 Well ID## ft
' --
tit. ft.
5a. Well Location: 20.DRILLING LOG(attach additional streets if necessary)
List all applicable well construction pertimts(le County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
SCOTT HUNDLEY
_ Oft. 14 fI. Brown Clay
Facility/Owner Name Facility ID(if applicable) 14 ft. 30 ft. Gray Hard Grande SET CASING
HENRY ROGERS RD HAYESVILLE 28904 Lot 30 ft. 606 ft. Gray Hard Granite
Physical Address.City,and Zip ft, ft•
Clay 556000446876 ft. ft.
County Parcel Identification No.(PIN) ft ft,
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft' .
If well field,one lat.9ong is sufficient) 21.REMARKS
35.041909 N -83.796976 w BIT SIZE 6.00"
6. Is(are)the well(s): Permanent
22 Certification:
7. Is this a repair to an existing well: No _y'!L 6/21/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Contractor Date
repair under#2/remarks section or on the back of this form. By signing this form,I hereby certifii that the wens)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 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 adtiional pages if necessary.
9.Total well depth below land surface: 605 (ft.)
For multiple wells list all depths if different(example-3(200'and 2 @ 1009 SUMITTAL INSTRUCTIONS
10.Static water level below top of calms 600 (ft.) 24a.For MI Wells: Submit this form within 30 days of completion of well
If water level is above casing,use"+" construction to the following:
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 air 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,Under•gr•orm Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(rpm): 0 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 j completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina De attment of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013