GW1--06195_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD I For Internal Use ONLY:
This form can be used for single or mutiple wells
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1.Well Contractor Information: 14:�YATER ZONES s , ,:
FROM TO DESCRIPTION
WILLIAM LAWSON 652 ft. 653 ft. I ?
Well Contractor Name 742 ft. 743 ft. ! '
NCWC3491A 15,OUTER CASING(for multi-cased wells)OR LINER(if apphcatilc)', 5
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ftft'60 6.125 I. ill' SDR 21 PVC plastic
Company Name ft. ft. ! in.
_ .,INNER CASING OR TUBING:(geothermal closed loop)
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2.Well Construction Permit#: 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 • 5
FROM TO DIAME1hK THICKNESS SLOT SIZE MATERIAL
Residential ft. ft i in.
ft. ., ft. in.
- 1&GROUT '46'_
— :F• >,i 7,7,'-'1 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ti t:: ,. :,.*71..- 1,-.•- 0 ft. 3 ft. Bentonite Pell tts 50 Gravity
O C T 43 1 2024 3 ft' 20 ft' Bentonite slu 150 Pumped/Tremie
ft ft
:x-,c u sf(. 19rS-4ND/GRAVEL PACK(if applicable)
:'ii is ,,i2.1-3 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft. j
4. Date Well(s)Completed: 10/8/2024 Well ID## ft. ft.
ft. • .ft. . ,. .
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)
TODD REGO. Oft 17• ft. n M Brown- • • •
Facility/OwuerNamne Facility ID(if applicable) 17 ft 60 ft. Gray Hard Granite Set Casing
887 CONLEY MOUNTAIN ASSOC RD WHITTIER 28789 Lot 60 ft. 652 ft. Gray Hard Granite
Physical Address,City,and Zip 652ft. 653 ft. Gray Fractured Granite Small Fracture 0.5 GPM
Swain 669200950970 653 ft. 742 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 742 ft. 743 ft. Gray Fractured Granite Small Fracture 0.5 GPM
5h. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 743 ft. 805 ft. Gray Hard Granite
(If well field,one lat/long is sufficient.) 21.REMARKS
35.389881 N -83.366734 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. Certifcatio
7. Is this a repair to an existing well: No ffr7c1- —10/10/2024
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 thisform. By signing tlris form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA 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: • 805 (ft.)
For multiple wells list all depths if different(example-3®200'and 2®100) SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 200 (ft.) 1
If water level is above casing,use'+" construction to the following: I,.
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 formiwithin 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality Undergromm Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 1 Method of test: Air 24c.For Water Supply Injection'Wells: In addtionto sending the form to
the address(es)above,also submit onelcopy 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. II
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013
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