GW1--06945_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells 1
14.WATER ZONES .- c 7" s ',
1.Well Contractor Information: s
FROM TO DESCRIPT)ON
WILLIAM LAWSON 137 ft. 138 ft.
Well.Contractor Name 587 ft 588 ft.
NCWC3491A 1S OUTER CASING(for multi-cased Wells)OR LINER(if applicable)!,,-z,V; ;;Itaii
NC Well Contractor Certification Number FROM TO DIAMETER I THICKNESS MATERIAL
CHEROKEE WELL DRILLING 0 ft 60 ft 6.125 I m SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING ORTUBING(geotlterinal closed loop) '
2.Well Construction Permit#: W2023000666 2023000238 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertmits(ie Count};State:Variance etc. ft. ft. in.
3.Well Use: ft ft. in.
17.SCREEN .- - _
FROM TO DIAME AN. THICKNESS SLOT SIZE MATERIAL
Residential ft ft. in.
ft. ft . in.
18.GROUT •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
7-..;',1 0 ft. 3 ft. Bentonite Pelletts 50 Gravity
. `r , e r�;' :7.••3.� ft ft.
3 20 Bentonite slurry 150 Pumped remie
�I ft. ft.
Nov 1 S ZO L4 19.SAND/GRAVEL PACK(if applicable)
z.;.,..;.,.',-v,3',3r,A FROM TO MA!liRIAL EMPLACEMENT METHOD&AMOUNT
IC,`G: ..__ ft. ft.
4. Date Well(s)Completed: 6/25/2024 Well ID# WARD PROP ft. ft. ,
ft ft
5a. Well Location: 20.DRILLING LOG(attach additional sheets if necessary) '
List all applicable well construction pertmits(Ie Count4 State,Variance,etc. FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
EVAN WARD 0 ft 37 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 37 ft. 60 ft. Gray Hard Granite Set Casing
698 WELLS RD MARBLE 2890S Lot 60 ft. 137 ft. Gray Hard Granite
Physical Address,City,and Zip 137 ft. 138 ft. Gray Fractured Granite Small Fracture 0.5 GPM
Cherokee 551300189249000 138 ft. 587 ft. Gray Hard,Granite •
County Parcel Identification No.(PIN) 587 ft. 588 ft. Gray Fractured Granite Small Fracture 1.5 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 588 ft 1645 ft. Gray Hard Granite
(If well field,one la/long is sufficient) 21.REMARKS
35.128857 N -83.980697 w BIT SIZE-5.98"
6. Is(are)the well(s): Permanent 1
22. Certification:
7. Is this a repair to an existing well: No i7PtL 7/1/2024
If this is a repair,fill out known well construction information and explain the nature of the a Signature of Certified Well Contractor Date
repair under 421 remarks or on the back.ofthis form.
Hp signing this form.I hereby certifi*that the well(s)Has(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NC4C 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 saute 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: 645 (ft.)
For nndtiple wells list all depths if different(example-3 a1200'and 2 @ 100) SUi<IITTAL INSTRUCTIONS '
10.Static water level below top of casing: 20 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
Ifwater Ievel 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: r
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,1Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 2 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'
13b. Disinfection type: HTH Amount: 100 completion of well construction to the county health department of the county
where constructed. I 1
Form GW-I North Carolina Department of Environment and Natural Resources -Division of Water Oualitv Revised Ian 2013
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