GW1--05361_Well Construction - GW1_20240909

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
WILUAM LAWSON 175 ft. 176 ft.
Well Contractor Name 242 ft. 243 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 1t. 67 ft. 6.625 in. 0.188 Steel-black
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2024000172 2022000287 _ FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction pertmits(te County,State,Variance,etc. ft. ft. in.
3.Well Use: ft. 1 ft. in. j
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. in.! 1
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
�`
'r'c:i,/E D 0 ft. 3 f1. Bentonite Pellettc 50 Gravity
` tr L. ,/ 1.. iJ 3 fk 20ft. Bentenite slurry 150 Pump
SEP 0 9 2024 ft. ft.
19.SAND/GRAVEL PACK(if applicable)
into: a k'r. l rr r ;_.9 ufa[ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
(7WCAOG ft. ft.
4. Date Well(s)Completed: 7/16/2024 Well ID#
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction pertmits(te County,State, Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
JOHN WILLIAMS 0 ft. 45 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if app&cabte) 45 ft. 67 ft. Gray Hard Granite Set Casing
5107 BOIUNG SPRINGS RD MURPHY 28908 Lot 67 ft. 175 ft. Gray Hard Granite
Physical Address,City,and Zip 175 ft. 176 ft. Gray Fractured Granite Small Fracture 5 GPM
Cherokee 551700003033000 176 ft. 242 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 242 ft. 243 ft. Gray Fractured Granite Small Fracture 8 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 243 ft. 305 ft. ' Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.213357 N -83.989042 W BIT SIZE- 5.96"
6. Is(are)the well(s): Permanent
22. Certification:
7. Is this a repair to an existing well: No jrrj 7/22/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certifi ell Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with/5A 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: 305 (ft.)
For multiple wells list all depths ifdifferent(example-3@ 200'and 2 @ 1009 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 Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary 24b.For Iniection 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): 13 Method of test: Air 24c.For Water Supply iniection 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