GW1-2021-00503_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Jeff Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
50 ft. 305 fr.
2050-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulI set)wells OR LINER if a livable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL,
0 ft. 30 ft- 6.25 SDR21 I PVC
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc) p ft. ft. in.
3.Well Use(check well use): fL fr. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(HeatinglCooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 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 f+• ft.
❑Experimental Technology ❑Subsidence Control r<. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)i
FROM ft, ft To DESCRIPTION color,hardness solUrock type in size etc.)
4.Date Well(s)Completed: 1/22/2021 shell M# ft. ft.
5a.Well Location: ft. fr.
Cherokee Enterprises/Dollar General ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Hwy 19 Ela, Bryson City, NC 28713 ft. f6
Physical Address,City,and Zip fr. fL
Swain 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 27' 11" N 83 degrees 23'27" W 1/22/2021
6.Is(are)the well(s): ItPermanent or ❑Temporary si D rtifi WeII Cftractor j Date
gy signing this form,I hereby certify that the wells)was(were)constructed in accordance wilt
7.Is this a repair to an existing well: ❑Yes or In No 15A NC'AC 02C.0100 or 15A NC'AC 01C.0200 Well Construction Standards and that a copy
If ihis is a repair,fill out known it-ell construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under-11 remarks section or on the hack ofthiss form. Ep- { 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wed-havin'''anc�
You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL- d AE o)`'Its (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: + 1 1 n 202� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 , 1 �A Submit this GW-1 within 30 da s' the per completion con wel
l ll following:
hor multiple wells list all depths i di erent(example-3 r 00'and 2 100) r"� ''` y p p
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ' `• (R.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
II'water level is above casing,use "
24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c For Water Supply and Open Loop Geothertal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental her,-ith 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) 10 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 12oZ
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
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