GW1-2021-03529_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
KalebT. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
40 e• 305 rt.
4436-A
ft. ft. j
r
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. 39 ft. 6.25 j in SDR21 I PVC
Company Name
16.INNER CASING OR TUBING eothet•mal closed-loop)'
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State, Variance,etc) 0 ft. 411 -
in.
3.Well Use(check well use): ft. j in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I 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 a licatile
❑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 DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.)
ft.
4.Date Well(s)Completed: 05/24/21 Well ID# ft. ft.
5a.Well Location: ft. ft.
David Dalton R. ft. v+
Facility/Owner Name Facility ID#(if applicable) ft. ft.
107 Tiber Estates, Bryson City, NC 28713 ft. ft. JUN
Physical Address,City,and Zip ft. ft. processing Urll
Swain 21.REMARKS PtOlin Sedan
,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
35 degrees 21' 22" N 83 degrees 26 6" W 5/24/2021
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6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of Certified I Contractor Date
' By signing this form,I hereby certify that the well(,)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 10200 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 421 remarks.section or on the back of this 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-I 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 ifdii ferent(example-3 a 00'and 2@100)10.Static water level below top of casing: 40 -
24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
(rwater level is above casing,use"+" I j -,
6.25 24b. For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and Open-I,�oop 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 o�er 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 4 Method of test: air
Permit Program,1611 MSC,Raleigh)NC 27699-1611
13b.Disinfection type: HTH Amount: 12 OZ
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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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