GW1--06238_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells I'
1.Well Contractor Information: 14.WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 138 ft. 139 ft. 1
Well Contractor Name ft ft I
NCWC3491 A 15.OUTER CASING(for muilti-esed wells)OR LINER(if applicable);:,
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 65 It 6.125 ' ilL SDR 21 PVC plastic
Company Name ft ft in.
16:INNER CASING OR TUBING(geothermal closed loop) 0
2.Well Construction Permit#: W20 240 0 0 28 7 FROM TO DIAMETER 1 H1CKNESS MATERIAL
List all applicable well construction pertrnits(ie County,State,Variance,etc. ft. ft. in.
3.Well Use: ft ft i fit
17.SCREEN .
FROM TO DIAME 1 hlt THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. : in•
ft. ft in.
. 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 3 f. Bentonite PeilPtts 50 Gravity
3 ft 20 ft Bentonite slurry 150 Pumped/'fremie
ft. ft. I
19.SAND/GILAVEL PACK(if applicable) • -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
ft. ft.
4. Date Well(s)Completed: 9/12/2024 Well ID#
. ft. ft. !-
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary)'
List all applicable well construction pertmits(ie County;State.Variance.eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
CASEY&CARROL LEDFORD 0 ft. 34 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 34 ft. 65 ft. Gray Hard Granite Set Casing
12050 HWY 294 MURPHY 28906 Lot 65 ft- 138 ft. Gray Hard Granite
Physical Address,City,and Zip 138 ft. 139 ft Gray FracturedGranite..SmallFracturea GPM;
Cherokee 452400039321000 139 ft. 305 ft. Gray Hard Granite County Parcel Identification No.(PIN) ft. ft. 0[T S 1 2024
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: ft ft'
(If well field,one lat/long is sufficient.) 21.REMARKS` lily,. r lfrc r _r•:':
C. v U 1. r"d am u
35.12654 N -84.282091 W BIT SIZE-6.00"
ti
6. Is(are)the well(s): Permanent /d
22. Certification;/), f�i
7. Is this a repair to an existing well: No � , °` -----" 10/14/2024
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 certtt&that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or I 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: 305 (ft.)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUMITTAL INSTRUCTIONS
24a.For All Wells: Submit this fomn within 30 days of completion of well
10.Static water level below top of casing: 20 (ft.)
Ifwater level is above cosine 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 fon n 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): 1 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 i 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
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