GW1--05973_Well Construction - GW1_20241009

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
14:WATEER ZO ES - Z i5:< N
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 372ft. 373 f I ,
Well Contractor Name 492 ft. 493 ft. I '
NCWC3491 A 15.OUTER.CASING(for midi!-eased wells)OR LIi�ERIf a pIICable)
NC Well Contractor Certification Number FROM TO DIAMETER I THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 it' 100 it 6.125 I'Ill'' SDR 21 PVC plastic
Company Name ft. ft. is ht.
16.IEER,CASING ORTUBE IG(geothermal closer!loop)
2.Well Construction Permit#: 022-1488 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(le County,State,Variance,etc. ft. ft. On.
in-
3.Well Use: ft. ft. �'
17.SCREEN ti i i.
FROM TO DIAMETER; THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. k In.
ft. ft. [in.
18"GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 it 3 B' Bentonite.l� tts_ 50.___ Gravity
t. ._.4`� ' t,. 7 3 R• 20 ft' Bent:4111te_SIIA `e
y�t i.... } t, ft. ft.
9 2024 19.'SAND/GRAAELYPACKK(i fapplica1de) " - ix
O r T O FROM TO MATERIAL;. EMPLACEMENT METHOD&AMOUNT
r, i_y t��A ft. ft. {
If,:�::`e
- , f. ft. I, :
4. Date Well(s)Completed: 8/29/2024 Well ID# I REs` K COVE
ft. ft. r ,
5a. Well Location: 20.DRIILItNG'I.OG(attach additional sheets if necessarg) _
List all applicable well construction pertmits(le County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc)
RICHARD&SANDRA FLEITES LOT 18 Oft 72 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 72 ft. 100 ft. Gray Hard Granite Set Casing
855 SLATE STONE LN HAYESVILLE 28904 Lot 18 FIRES CREEK COVE 100 ft. 372 ' ft. Gray Hard'Granite
Physical Address,City,and Zip 372 ft. 373 ft. Gray Fractured Granite Small Fracture 1 GPM
Clay 554200724643 373 ft. 492 ft. Gray Hard;Granite
County Parcel Identification No.(PIN) 492ft. 493 ft Gray Fractured Granite Small Fracture 1 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 493 ft. 605 ft. Gray Hard,Granite
(If well field,one lat/long is sufficient) 21.REMARKS; ., - .`"
35.087725 N -83.857032 w BIT SIZE-6.02" i'.
6. Is(are)the well(s): Permanent I
22. Certification: ¢
7. Is this a repair to an existing well: No - 10-/�rdu1?? - 8/29/2024
If this is a repair,fill out known well construction Information and explain the nature of the Signature of Certified We Contractor Date
repair under#21 remarks section or an the back of this form. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance -
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200!Veil Construction Standards and that a
8. Number of wells constructed: _1 t. 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 laird surface: 605 (ft-) �;
For multiple wells list all depths if di,fjerent(example-NO 200'and 2(d1100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit tins form within 30 days of completion of well
10.Static water level below top of easing: 200 (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 Injection Wells: In addtion to sending the fonts 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: i
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 Supply Injection Wells: In addtion to sending the form to
the address(es)above,also submit ona 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. I
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Outdity Revised Jan 2013
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