GW1-2021-06783_Well Construction - GW1_20210809

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
100 ft- 305 ft-
4436-A ft. ft.
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. 85 ft- 6.25 1 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(/IC,County,State, Variance,etc.) 0 ft. et in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
R
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supplv(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 applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. TO fr. DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.
4.Date Well(s)Completed: 07/07/21 well ID# ft. ft
ft. ft.
5a.Well Location:
Deep Creek Elk Hollow rt. rt.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Elk Hollow, Bryson City, NC 28713 ft. ft-
Physical Address,City,and Zip ft. ft. JAUU t 1 1'
Swain 21.REMARKS C .G- V
Iri#arrl', R Ser"",
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22.Certification:
35 degrees 27' 36" N 83 degrees 26' 35" w
� G � 7/7/2021
6.Is(are)the well(s): CPermanent or ❑Temporary Signature re�
Contractor 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 ONo /SA NCAC:02C.0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a copy
1f 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 921 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: 305 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple welds list all depths ifdti1erent(cxanrple-3 rr 200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
]0.Static water level below top of casing: 100 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ffwater 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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
(�_ Permit Program,1611 MSC,Raleigh;NC 27699-1611
J
13a.Yield(gpm) Method of test: air
13b.Disinfection type: HTH Amount: 9 oZ
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018