GW1--06038_Well Construction - GW1_20241011

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or mutiple wells 4 ,
14.WATER ZONES . ` t"` j
1.Well Contractor Information:
FROM TO DESCRIPTION
WILLIAM LAWSON 195 ft. 196 ft.
Well Contractor Name 217 ft. 218 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 tI• 80 ft• 6.125 i in. SDR 21 PVC plastic
Company Name ft. ft. , in.
16.INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: W2024000123 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, r
' 1
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. in.
ft. ft. in.
18.GROUT )
-- - -- - -FROM-- -TO MATERIAL- - . EMPLACEMENT METHOD&AMOUNT
0 ft• . 3 ft. Bentonite Pelletts 50 Gravity
3 ft. 20 ft• Bentonite slurry 150 Pumped/Tremie
ft. ft.
19:SAND/GRAVEL PACK.(if applicable) i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
ft. ft.
4. Date Well(s)Completed: 7/17/2024 Well ID# ft. ft.
i.
ft. ft. I,
5a. Well Location: 20.DRILLING•LOG(attach additional sheets if necessary) • '
List all applicable well construction pertmits(le County,State,Variance,etc. FROM TO • DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
MICHAEL STRADER 0 ft. 48' ft. Brown'Medium Slate
Facility/Owner Name Facility ID(if applicable) 48 ft. 80' ft. Gray Hard Granite Set Casing
73 MORNINGSIDE LN MURPHY 28906 Lot 22 80 ft. 195' ft. Gray Hard Granite
Physical Address,City,and Zip 195 ft. 196 ft. Gray Fractured Granite Small Fracture 5 GPM
Cherokee 447900690944000 196 ft. 217 ft. Gray Herd Granite
County Parcel Identification No.(PIN) 217 ft. 218 ft. Gray Fractured Granite Small Fracture 5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 218 ft. 305 ft. Gray Hard Granite. „- r-, ,.T,
(If well field,one lat/long is sufficient.) 21.REMARKS, _ k, fi•• V R T., i
35.015845 N -84.091986 W BIT SIZE-6.00" - ' , p r T 1 s 2024
6. Is(are)the well(s): Permanent
22. Certi cat' n• ,. lrt "-,i`.7. i .- _•,:.•.',;;�i9
A �.' i' D'
7. Is this a repair to an existing well: No ? %a" C 3 7/23/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified 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 15A 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.) I'
For multiple wells list all depths if different(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: 80 (ft) construction to the following: i'
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
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: I 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): 10 Method of test: Air 24c.For Water Supply Yniection 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 constructioni 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