GW1-2021-00964_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
20 ft. 255 ft.
2050-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 85 ft- 6.25 in 188 Steel
Company Name -16.INNER CASING OR TUBING eothermaI closed-loop)
2.Well Construction Permit#' FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Sate,Variance,etc.) 0 1E ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
t ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: 0- ft. 17 ft.
onitoring ❑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,gritin sire,etc.)
4.Date Well(s)Completed: 03/08/2021 well ID# ft. ft.
5a.Well Location: ft. ft. t -1
Terry Charles rt. ft. E
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Yellow Creek, Robbinsville, NC 28771 ft. ft. �s
�e ft. ft. '
Physical Address,City,and Zip � C SSI 0
Graham 21.REMARKS
Y
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: LL//
35 degrees 24'45" N 83 degrees 49' 53" W az�
Y 3/8/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Sig (itid ertif Well tractor Date
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 (nNo 15A NCAC 02C.0100 or I5A 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 o/7he ojthis record has been provided to the well owner.
repair under 911 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 255 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiereni(example-3 a 100'and 2 a@I00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 20 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
f water level is above casing,use"+"
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) 60 Method of test: air '
13b.Disinfection type: HTH Amount: 9 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018