GW1-2021-01524_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: p (°! ` /
Jeff Hyde E-CEI\ 14.WATER ZONES
Well Contractor Name 1 FROM TO DESCRIPTION
2�2
2050-A MAR X 20 ft- 305 ft.
NC Well Contractor Certification Number ation Processing
n� ft. ft.
Inlorm pwR$ 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC Section FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 110 fir- 6.25 i" 188 Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fir- 17 ft.
❑Monitoring ❑Recovery 17 - ft. 20 ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiUrock a fain sine,etc.
ft. ft.
4.Date Well(s)Completed: 2/25/21 Well ID# ft. ft.
ft. ft.
Na.Well Location:
John Barlow ft. fL
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Tallulah Rd, Robbinsville, NC 28771 ft. ft.
Physical Address,City,and Zip ft. ft.
Graham 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certification:
35 degrees 16' 13 " N 83 degrees 43' 50" W 2/25/2021
6.Is(are)the well(s): ClPermanent or ❑Temporary Signa tfie ell Co ctor Date
By signing this jarnt,l hereby certify that the well(s)was(were)constructed in accordance with _
7.Is this a repair to an existing well:- -❑Yes or (!nNo 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 rentarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only i GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiereni(example-3@200'and 2@/00')
24a. For All Wells: Original form to Division of Water Resources (DR),
If Static water level below top of casing: 20 (ft.)
W
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is abase casing,use"�" rm
6.25 24b. For injection Wells:Copy to DWR,Underground Injection Control(iUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 12 oZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018