GW1--05070_Well Construction - GW1_20240827

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 - - -
- -- - _ -_ --- --- 240 ft. 241 ft.
Well Contractor Name
352 ft. 353 ft.
NCWC3491A 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft. 120 ft. 6.125 in. SDR 21 PVC plastic
Company Name ft ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2024000343 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmts(ie County,State,Variance,etc. ft. ft. in.
3.Well Use: ft. ft. in. I -_
17.SCREEN
FROM TO DIAMETER THICKNES' SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT ..
r-- - i .-. 17 ^i FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
6'-..;,,.,s...•L. "l l ..f^.• 0 ft. 3 ft Bentonite Peileits 50 Gravity
AUG 2
2024 3 it 20 ft Bentoniteslurry 150 Pumped/Tremie
ft. ft.
�� ,y UPI' 19.SAND/GRAVEL PACK(if applicable)
lr,i i:: : � FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
Lifu.%'�C ft. ft.
ft. ft.
4. Date Well(s)Completed: 8/19/2024 Well ID# NEWTON PROP
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO - DESCRIPTION(color,hardness,soilrock type,grain size,etc)
SALLIE RUTH NEWTON PAR 4 0 ft. 97 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 97 ft. 120 ft. Gray Hard Granite Set Casing
136 SHOOTERS LN MARBLE 28905 Lot 120 ft. 240 ft. Gray Hard Granite
Physical Address,City,and zip 240 ft. 241 ft. Gray Fractured Granite Small Fracture 0.5 GPM
Cherokee 551404509949000 241 ft. 352 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 352 ft. 353 ft. Gray Fractured Granite Small Fracture 1.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 353 ft. 405 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.133931 N -83.967133 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. Certiticati Q �
7, Is this a repair to an existing well: No U 24
If this is a repair,fill out known well construction information and explain the nature of the Signature of ' ed ell Contractor Date
repair under k 21 remarks section or on the back of this form. By signing this form,1 hereby certify that the well(s)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 additional pages if necessary.
9.Total well depth below land surface: 405 (ft-)
For multiple wells list all depths if different(example-A@ 200'and 2 @ 100) SUMITTAL INSTRUCTIONS
10.Static water level below top of casing: 40 (ft.) 24a.For All Wells: Submit this form within 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,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 2 Method of test: Air 24c.For Water SUDDiv 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