GW1--04848_Well Construction - GW1_20240814

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 125 ft. 126 ft.
Well Contractor Name ft. R
NCWC3491A 1&OUTER CASING(lise multi-cased wells)OR LINER(Ifappikable) m
NC Well Contractor Certification Number FROM TO DIAMETER ! THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft60ft• 6.013 hn' SDR 21 PVC plastic
Company Name ft ft in.
2.Well Construction Permit#: W2024000067 2023000731 ROM ro - 8 AM T Hi mal closed loop)
FROM TO DIAMETER TIIIC h1ESS M TERLU
List all applicable well construction pertmits lie County,State.Variance.eta ft. ft. in.
3.Well Use: ft. ft. in.; -
117.SCREEN
FROM TO DIAMETER ` THICKNESS SLOT SIZE \LAIERIAL
Residential ft. ft. in I
ft ft. in..
}r-,--3 �. l&GROUT
t �a.`�..d i,.. \I-L.') FROM TO \LATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft 3 ft Bertlonite Pelletts 50 Gravity
AUG 1 4 2024 3 ft 20ft• Bentonite slurry 150 Pumped/Tremie
ft. ft.
I rrt'`S::r.E.`c n P C, A9i ti UP "{tEL PACK(if applicable) Will
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
ft. ft.
4. Date Well(s)Completed: 7/12/2024 Well ID#
ft. ft.
Se. Well Location:
List all applicable well construction perteuts(ie County,State,lrarianc%eta FROM TO DESCRIPTION C PTION(color,hardness,soilhadc type,gait size,etc) - -
TERAIL&KATHREN CLONTS Oft. 38 ft. Brown Medium Slate
Facility/Owner Name Facility D(if applicable) 38 ft. 60 ft. Gray Hard Granite Set Casing
2286 HWY 294 MURPHY 28906 Lot 60 ft. 125 ft. Gray Had Granite
Physical Address,City.and Zip 125 it. 126 ft. Gray Fractured Grange Small Fracture 10 GPM
Cherokee 455100559834000 126 ft. 205 ft Gray Hard Granite
County Parcel Ideatificatien No.(PIN) ft. ft,
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft' ft.
(Ifwell field,one lat'long is sufficient.) 21•REMARKS
35.0574 N -84.161232 W BIT SIZE-5.66"
6. Is(are)the well(s): Permanent
22. Certification
7. Is this a repair to an existing well: No ;., .07 7/15/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature ofCeitif •Well Contractor Date
repair under#21 remarks section or on the back of this form. By signing this fret,I hereby certify that the well(s)was(were)constructed in accordance
with 15ANCACO2C.0100or15ANCACO2C.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 infection 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-)
For multiple wells list all depths tf 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: 40 (ft.) construction to the following:
If water level is above casing,use"+"
Division of Water Quality,Information P.wcaalon Unit,
11. Borehole diameter: 6 (ha.) 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): 10 Method of test: Air 24c.For Water Simply 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 Jan 2013