GW1--05974_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or mutiple wells
14:WATER ZONES . • i...
1.Well Contractor Information:
FROM TO DESCRIPTION 1
WILLIAM LAWSON 513 ft. 514 ft. I '
Well Contractor Name ft. ft. I.
NCWC3491 A 15.OUTER CASING(for nndti-cased wells)OR•LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft" 47 ft• 6.125 Pr'' SDR 21 PVC plastic
•
Company Name ft. ft in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: 022-1472 FROM TO DIAMETER ' THICKNESS MATERIAL
List all applicable well construction permits(ie County,State,Variance,etc. ft ft. in •
3.Well Use: ft. in.
17.SCREEN -
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential - ft ft. 'in.
ft ft. jin-
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
f::::_;t..,::,#•,11 'D 0 fk 3 ft. Bentonite Pelletts 50 Gravity
t 3 ft 20 ft. Bentonite slurry 150 Pumped/Tremie
OCT 0 9 2024 ft. ft. .
' 19.SAND/GRAVEL PACK(if applicable) .
lr. iatt
.3, -'.';7 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Dqc.'i;2 0:0 ft. ft.
ft. ft- I.
4. Date Well(s)Completed: 8/1/2024 Well ID# MISSION RIDGE SUBft. ft. 1
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,soil/rock type,grain size,etc)
SPENCE WHARTON LOT 15 0 ft 18 'ft. Brown Medium"Slate -
Facility/OwrierName - FacilitylD(ifapplicable) 18fk 47 ,ft. Gray Hard Granite Set Casing
400 MISSION RIDGE DR HAYESVILLE 28904 Lot 15 .47 ft. 513 ft. Gray Hard Granite •
Physical Address,City,and Zip 513.ft: 514 ft. Gray Fractured Granite Small.Fracture 0.25 GPM
Clay 553100059641 514ft. 605 ,ft. Gray Hard Granite
County Parcel Identification No.(PIN) ft. ft. ,
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft.
(If well field,one lat/long is sufficient.) 21..REMARIKS
35.066896 N -83.912568 W BIT SIZE-5.67" I,
6. Is(are)the well(s): Permanent ,
22. Certification: , •
7. Is this a repair to an existing well: No r//,i e-0 8/6/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified Well Contractor , Date
repair under#21 remarks section or on the back of this form. By signing this fora.I hereby certify that the well(s)vim(were)constructed in accordance
with ISA NC.4C 02C.0700 or I SANCAC 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: 605 (ft.)
For multiple wells list all depths if different(example-3(41200'and 2©100') SUMITTAL INSTRUCTIONS
10.Static water level below top of casing 500 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Ifwater 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
I.
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): 0.25 Method of test: Air 24c.For Water Supply Injection Wells: In addtionto 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 O{ality Revised Jan 2013