GW1-2021-07099_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KalebT. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
75 ft• 805 ft.
4436-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-caseddwells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 fr• 91 fr• 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 well construction permits(i.e.I/V,County,State, Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in..
❑Geothermal(Heating/Cooling Supply) PJResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rr' 17 ft.
❑Monitoring ❑Recovery 17 rt. 20 ft.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑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. ft.To DESCRIPTION(color,hardness,soiVirock type,gmin size,etc.)
4.Date Well(s)Completed: 08/06/2021 Well ID# ft. ft.
ft. ft.
5a.Well Location: «.
Steve Day
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. �� �
Fontana Lake Estates, Lake Ridge Drive, Bryson City, NC 28713 ft. ft. O
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS
County Parcel Identification No.(PIN) ^, ^ii •` ,lg J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
35 degrees 23' 8" N 83 degrees 33' 8" W " 8/6/2021
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified 11 Contractor Date
By signing this form,]hereby certify ihm the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No ISA NCAC 02C.0100 or/SA NCAC 02C'.0200 Well Construction Standards and that a copy
Ifthi.s is a repair,fill out known well construction in/onnation and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back gJ7his 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 805 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple ivefis list all depths ifdi/ferent(example-3@200'and 2@100')
75 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
lflvater level is above casing,use
11.Borehole diameter: 6.25 (in.) 24b. For Infection 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-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmeptal 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) 1'S Method of test: ale
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 30 OZ
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018