GW1--05977_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD 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 - 570 ft. 571 ft. I '
Well Contractor Name
ft ft I I
NCWC3491A 15.OUTER CASING(for multi-Cased nells)OR LINER(If apphgible) .` _
NC Well Contractor Certification Number FROM TO DIAMETER I, THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft' 45 ft 6.125 I i°' SDR 21 PVC plastic
Company Name ft- R I in
16.INNER CASING ORTU LING(geothermal closed loop) ' ` 4?ze,
2.Well Construction Permit#: W2023000576 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie County;State,Variance,etc. ft. ft :in.
3.Well Use: ft. ft ;in
17.SCREEN
FROM TO DIAMETER; THICKNESS SLOT SIZE MATERIAL
Residential ft. ft I'in.
ft ft I in.
18.GROUT 44a?` a `.Mt;4 _
- -- FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT'
'''3`: FO 0 ft3 ft* Bentonite Pelletts 50 Gravity
3 ft 20 ft' Bentonite slurry 150 Pumped/Tremie
0(;I 0 y 2024 ft. ft.
19.SAND/GRAVEL PACK(if applicable) ' f ,
•iriv-s::74..i'"-; it'r�`f 7. I FROM TO MATERIAL' EMPLACEMENT METHOD C AMOUNT
Cj:i ^ S ft. ft. I'
ft. ft. P
4. Date Well(s)Completed: 5/7/2024 Well ID# DEERWOOD MOUNTAI
ft. ft.
5a. Well Location: 20:DRILLING LOG G(attach additional sheets if necessary)
List all applicable well construction pertnrits(le County,State,Variance,eta
FROM TO DESCRIPTION(color,hardness,spilhpck type,grain size;etc)
WILLIAM CUTLER LOT 34A Oft. 8 ft. Brown Medium Slate
Facility/OivnerName Facility ID(if applicable) 8 ft. 45 ft Gray Hard'Granite Set Casing
15 TROPHY BUCK PT MURPHY 28906 Lot 34A DEERWOOD MOUNTAIN EST 45 ft. 570 ft. Gray Hard!Granite
Physical Address,City,and Zip 570 ft. 571 ft, Gray Fractured Granite Small Fracture 0.1 GPM
Cherokee 454002963038000 571 ft. 700 ft. Gray Hard;Granite
County Parcel Identification No.(P111) 700ft 805 ft. Gray Hard;Granite
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft. ft
(If well field,one lat/long is sufficient.) 21.REMARKS ? _
35.029815 N -84.182078 ;R BIT SIZE-5.75" 1
6. Is(are)the well(s): Permanent 22. Certtficatiot X21,7. Is this a repair to an existing well: No hJ_ j j,� 5/13/2024
If this is a repair,fill out known well construction information and explain the nature ofthe Signature of Certifie Well Contractor Date
repair under+r 21 remarks section or on the back of thisform. By signing this form,I hereby cerhfi'that the wel(s)was(were)constructed in accordance
with 1 SR NCAC 02C.0100 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: 805 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUMITI AL INSTRUCTIONS
I.
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 60 (ft.)
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: I
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,jUndergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 0.1 Method of test: Air 24c.For Water Supply Infection Wells: In addtionto sending the form to
the address(es)above,also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b. Disinfection type: HTH Amount: 100 where constructed. I i
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013
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