GW1-2021-03533_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
'
FROM TO DESCRIPTION
Well Contractor Name 15 ft- 205 ft.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a` licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 66 ft- 6.25 i" SDR21 PVC
Company Name 16,INNER CASING OR TUBING eothermal closed-loon)
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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl 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 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 ft. To ft. DESCRIPTION(color,hardness,soil/mck type,gnin si.,etc.)
4.Date Well(s)Completed: 05/26/21 Well ID# ft. ft.
5a.Well Location: ft. ft. LJ
^'_ ( 6 ,, `�
Lehman Coday ft. ft. tl
Facility/Owner Name Facility ID#(if applicable)
ft. ft. J zi
U N X ?
Coday Road, Bryson City, NC 28713 ft. ft. .t
Physical Address,City,and Zip ft. ft. 1 n To,I I it",At i
i.on
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 25' 12" N 83 degrees 28' 27" W
5/26/2021
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature ofCertifie ell Contractor Dace
By.signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature of the of this record has been provided to the well Downer.
repair under 921 remarks section or on the back of7his 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 1 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: 205 (ft.)
For multiple wells list all depths tftli ferem(example-3@200'and 2@100') Submit this GW-1 within 30 days oflIwell completion per the following:
15 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC?Raleigh,NC 27699-1617
lfwater level is above casing,use" i 1 i
11.Borehole diameter 6.25 (in.) 24b.For Injection Wells:Copy to DI WR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and Open-Loon 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
Permit Program,1611 MSC,Raleigh, 27699-1611
13a.Yield(gpm) 25 Method of test: air ,
13b.Disinfection type: HTH Amount: 9oZ
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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