GW1--06362_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells ,
1.Well Contractor Information: 14.WATER ZONES
FROM TO DESCRIPTION
WILLIAM LAWSON 265 ft 266 ft.
Well Contractor Name 377 ft 378 ft I ,
NCW03491 A 15.OUTER CASING(for inniti-cased wells)OR LINER if applicable), ,
NC Well Contractor Certification Number FROM TO DIAMETER 1 THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 115 ft. 6.125 j ill' SDR 21 PVC plastic
Company Name ft ft. in.
16.INNER CASING OR TUBING(geothermal closed loop) ,-.
2.Well Construction Permit#: W20 240 0 0 249 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertnsits(ie County,State,Variance,eta ft. ft. ' in.
3.Well Use: ft. ft i in.
17.SCREEN
FROM TO DIAMETER THICKNESS SLOT SIZE MATERIAL
Residential ft. ft. , in.
ft. ft in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
r ;= ');�,. ft. ft.
tt + 0 3 Bentonite Pelletts 50 Gravity
®. t,a., 4�r;.A."• o �. s , i ft. ft.
r a t.,, 3 20 Bentonite slurry 150 Pumped/Tremie
ft. ft
OCT2 2024 2024 19.SAND/GRAVEL PACK(if applicable)
li i•.:3;7 , !t:..2 DV F„,,;/. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
''r"'°rs t ft. ft
ft. ft.
4. Date Well(s)Completed: 8/21/2024 Well ID#
ft. ft.
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary) -
List all applicable well construction pertmits fe County,State,Variance,eta FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
WILLIAM REGGIE PENDLEY Oft 93 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 93 ft. 115 ft. Gray Hard Granite Set Casing
205 BEECHNUT LN MARBLE 28905 Lot 115ft 265 ft. Gray Hard Granite
Physical Address,City,and Zip 265 ft. 266 ft Gray Fractured Granite Small Fracture 1.5 GPM
Cherokee 551300953054000 266ft. 377 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 377 ft. 378 ft. Gray Fractured Granite Small Fracture 2.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 378 ft 405 ft Gray Hard Granite
(If well field,one lat/long is sufficient) 21.REMARKS
35.11891 N -83.954022 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent
22. CertificationY i
7. Is this a repair to an existing well: No � 8/27/2024 •
If this is a repair,fill out brown well constn ction information and explain the nature of the Signature of Certified Well Contractor Date
repair under#21 remarks section or on the back ofilmis form By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISANCAC 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 laud surface: 405 (ft-)
For multiple wells list all depths if different(example-3@ 200'and 2 @ 100') SUMI TAL INSTRUCTIONS
24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 40 (ft-)
Ifwater 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 Injection Wells: In addtion to sending the fonn to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this foim 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): 4 Method of test: Air 24c.For Water Supply Injection Wells: In addtion to sending the fornm.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 iI
Form GW-1 North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013