GW1-2021-00504_Well Construction - GW1_20210210

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeff Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
300 ft- 805 ft.
2050-A ft ft.
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NC Well Contractor Certification Number I&OUTER CASING for multi-cased wells OR LINER if a' Gcable
FROM TO DIAMETER._ TIHCIQYFS�, . _MAW.Graham Well Drilling LLC
0 ft 49' ft 6 25, Ia SDR21 PVC
Company Name 16.INNER CASING OR.TUBING. "eothermal closed-loop)
2.Well Construction Permit#: FROM - `. TO ,,DIAMETER THCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft ft. is
3.Well Use(check well use): ft ft17.SC
Water Supply Well: FROM REE TO DIAMETER! SLOT SIZE TRICKINESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. io,'
❑Geothermal(Heating/Cooling Supply) inResidential Water Supply(single) ft ft in..
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 17 ft.
❑Monitoring ❑Recovery 17 fL 20 ft
Injection Well: -
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Stbilige and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTIONmbr,baldness soillrock size etc
ft ft.
4.Date Well(s)Completed: 01/14/2021 Well ID# ft. ft
ft. ft
5a.Well Location:
M.Wiggins Builders ft ft
Facility/Owner Name Facility ID#(if applicable) fL ft
Lot#33 Rock Ledge, Bryson City, NC 28713 ft. ft.
Pbysical Address,City,and Zip ft ft
Swain 2LREMARKS ' ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35 degrees 21' 1" N 83 degrees 34' 54" W 1/14/2021
6.Is(are)the well(s): dPermanent or ❑Temporary Si mfi ll tractor i Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form
23s 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 onl 1 GW-I is needed. Indicate TOTAL NUMB 13,s f welts a' qXdJ * (�dd'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 805 Submit this GW-1 within 3o dayslof well completion per the following:
For multiple wells List all depths tfdifferent(example-3@200'and 2q
10,Static water level below top of casing: 300 *),,r24a;`,For All Wells: Original form to Division of Water Resources (DWR),
611f rmation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+
6.25 tY' 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and Openmtoop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environments healthdepartment of a countywhere installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 2 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-10 1 1
13b.Disinfection type: HTH Amount: 24 oz
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018