GW1-2021-00963_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeff-Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
200 fit- 630 ft.
2050-A
fit. fit.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells TO LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 fit• 110 ft- 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2 THICKNESS MATERIAL
FROM TO DIAMETEI
List all applicable well construction permits(i.e.UIC,County,Sate,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 ft.
❑Monitoring ❑Recovery 17 fr. 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 fit. fit. ,To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed: 3/11/2021 Well ID# ft. ft. q
Sa.Well Location:
John Perkins
Facility/Owner Name Facility ID#(if applicable) ft. ft. A 021
Upper Sawyers Creek, Robbinsville, NC 28771 ft. ft. S
Unit
Physical Address,City,and Zip ft. ft. ii 1{vfl„D't,1 1 asp c
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 23' 50" N 83 degrees 43' 35" W 3/11/2021
6.Is(are)the well(s): [nPermanent or ❑Temporary Sign e ' Tif eft C,,*actor Date
By signing This fibrin,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 01C.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 411 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 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: 630
For multiple wells list all depths ifdii erent(example-3 a 200'and 2 a@100') Submit this GW-1 within 30 days of well completion per the following:
200 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fit.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaterlevel is above casing,use
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(ILIQ
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) 3 Method of test: air
Permit Program, 1611 MSC,Raleigh;NC 27699-161 1
13b.Disinfection type: HTH Amount:ae oZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018