GW1-2021-07090_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
75 ft. 805 fr.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR iLINER if a licable .
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 R• 134 tr• 6.25 I sDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell c•onstrucitan permits(i.e.(IIC,County.State,Variance,etc.) 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) CJResidential 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 S 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 licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage
rt. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional iheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiVrock type,grain sin,etc.)
ft. ft.
4.Date Well(s)Completed: 08/20/21 well ID# ft. ft.
5a.Well Location: ft. ft. e,v :gip
David Kenise ft. ft. �" a
Facility/Owner Nalne Facility ID#(ifapplicable) ft. ft' �.,�" O
Fontana Lake Estates, Alarka Point ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS rya°`' l
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 23' 35" N 83 degrees 33' 16" w � 8/20/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certifiedll Contractor Date e
By,signing this form,I hereby certh,that the a ell(s)it-as(irere)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
1f this is a repair,fill out knouvn me//construction information and explain the nature of the of'This record has been provided to the ire//on•ner.
repair tinder fill remarks section or on the back of this Jorin.
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: 805 (ft.)
For multiple wells list all depths ifdierent(example-3@200'and 2 a 100') Submit this GW-I within 30 days of well completion per the following:
10. 7rj 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If pater level is above casing,use"�"
11.Borehole diameter- 6.25 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and Open-tLoop 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 producinglover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13a.Yield(gpm) 1 Method of test: air �
13b.Disinfection type: HTH Amount: 30 oZ
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018