GW1--05975_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD Forinternal Use ONLY:
This form can be used for single or mutiple wells ! ,
14.WATER ZONES' •
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 389 ft. 390 ft.
Well Contractor Name 462 ft 463 ft
N CW C3491 A 15.OUTER CASING(for multi-casedwells)OR LAVER(rf apphci,ble)
NC Well Contractor Certification Number FROM TO DIAMEIEKI THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 40 ft" 6.125 us. SDR 21 PVC plastic
Company Name ft ft in.
16.INNER CASING OR TUBING(geothermal closedioop) h, :to
2.Well Construction Permit#: W2024000344 FROM TO DIAMETER THICKTNESS MATERIAL
List all applicable well construction pertmits(ie Count};State,Variance,etc. ft ft. I in.
3.Well Use: ft ft. in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MA LbHIAL
Residential ft ft j in.
ft ft in.
18 GROUT
. _. _ FROM TO . MATERIAL EMPLACEMENT METHOD&AMOUNT
T-^;- ; � {,,.rr 0 R• 3R- Bentonite Pell tts 50 Gravity
jr.,;,' �-- 3ft 20 ft. Bentonite slur 150 Pumped/Tremie
� LO2p ft. ft
nn
l' `T 0 9 't 19.SAND/GRAVEL PACK(if applicable)
f - I_t #i FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
4. Date Well(s)Completed: 8/10/2024 Well ID# ft. ft. j
ft. ft. j
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)
List all applicable well construction permits(le County,State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
RALPH BROWN 0 ft 22 ft. Brown Medium Slate T
Facility/Owner Name Facility ID(if applicable) 22 ft 40 ft. Gray Hard,Granite Set Casing .
2723 DICKEY RD MURPHY 28906 Lot - 40 ft. 389 .ft Gray Hard,Granite •
Physical Address,City,and Zip 389 ft. 390 ft. Gray Fractured Granite Small Fracture 0.5 GPM
Cherokee 445900595144000 390 ft. 462 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 462 ft. 463 ft. Gray Fractured Granite Small Fracture 1.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 463 ft 505 ft. Gray Hard,Granite
(If well field,one lat/long is sufficient) 21.REMARKS
35.01175 N -84.159764 W BIT SIZE-5.42"
6. Is(are)the well(s): Permanent
22. Certification: _ f
7. Is this a repair to an existing well: No e 8/13/2024
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 form,I hereby cerhfi'that the well(s)was(were)constructed in accordance
with 15A rVCAC 02C.0100 or 15ANCAC 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: 505 (ft.) i
For multiple wells list all depths if different(example-3©200'and 2 Ca1100) SUMFI'TAL INSTRUCTIONS
i1
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 100 (il.)
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: I`
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpnr): 2 Method of test: Air 24c.For Water Supply 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-1 North Carolina Department of Environment and Natural Resources -Division of Water Ouhlity Revised Jan 2013