GW1--05233_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD I 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 192 ft. 193 ft.
Well Contractor Name 341 ft 342 ft.
NCW C3491 A 15.OUTER CASING(for multi-cased welts)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 tt $0 6.125 bs• SDR 21 PVC plastic
Company Name ft. ff. In.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 022 1474 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County State,Variance,eta r ff. ft. In.
3.Well Use: ft ft' in.
i [17.SCREEN
LROM I TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential I ft. ft. ht.
r---
ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
_^ . -u onite Pelletts 50 Gravity
E113 I ft* :•ut•Ilk" slurry 200 PumpedJTremie
SEP ) 3 2024 f. ft-
19.SAND/GRAVEL PACK(If applicable)
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft.
ff. ft.
4. Date Well(s)Completed: 8/6/2024 Well ID# MISSION RIDGE LOT 4 ' - - -
C ff. ft. •
Se Well Location: _---_-...._1_..________--._.__._--
20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(ie County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil'rock type,grain size,etc)
HOPTON LAND HOLDINGS LLC LOT 43
Off. 62 ft. Brown Medium Slate - - -Facility/Owner Name Facility ID(if applicable) 62 ft. 80 ft. Gray Hard Granite Set Casing
NANTAHALA LN HAYESVILLE 28904 Lot 43 MISSION RIDGE 80 ft. 192 ft. Gray Hard Granite
Physical Address,City,and Zip 192 ft. 193 ft. Gray Fractured Granite Small Fracture 2 GPM
Clay 553100276220 193 ft. 341 ft. Gray Hard Granite
County Parcel Identificatim No.(PIN) 341 ft. 342 ft. Gray Fractured Granite Small Fracture 3 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 342 ft. 405 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.071416 N -83.907368 w C BIT SIZE-5.80"
6. Is(are)the well(s): Permanent
22. Certitkation:
7. Is this a repair to an existing well: No -+ 8/13/2024
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. Ily signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1.14 NCAC 02C.0100or 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-3@ 200'and 2 @ 100') SUMITI'AL INSTRUCTIONS
10.Static water level below top of casing: 100 (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 (In.) 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 Mall Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 5 Method of test: Air 24c.For Water Supply Infection 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 Ouality Revised Jan 2013