GW1-2021-06781_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
300 ft- 805 ft.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for It'
-cased'wells OR LINER if a ],'cable
Graham Well Drilling LLC FROM TO DIAMETER THI
mul CKNESS MATERIAL
0 ft. 1104 ft- 16.25 in SDR21 I 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.UIC,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 i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 17 ft.
❑Monitoring ❑Recovery 17 rt. 20 ft.
Injection Well:
fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a ],'cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control rt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
(color,
❑Geothermal(Heating/Cooling Return)
) ❑Other(explain under#21 Remarks) ft. TO ft. DESCRIPTION hardness,soiltrock type,grain size,etc.)
4.Date Well(s)Completed: 07/30/2021 well ID# ft. ft.
Sa.Well Location: ft. ft.
Fontana Lake Builders a. ft. 4�
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Fontana Lake Estates,Appalachian Way,Wild Orchard Trail,Bryson City,NC 28713 rt. ft. ,
Physical Address,City,and Zip it. ft. p `Oty
21.REMARKS
Swain
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' 15" N 83 degrees 32' 21" W 7/30/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCerti d w on tractor Date
By signing this form,I hereby certify that the well(s)was(here)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
If this is a repair.Jill 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: 805 (ft.)For multiple wells list all depths'lfdiffereni(example-3 rr 100'and 1@I00') Submit this GW-1 within 30 days of well completion per the following:
300 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
If water level is above casing,use"+"
24b.For Injection Wells:Copy to IDWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (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
13a.Yield(gpm) 'S Method of test: air
Permit Program, 1611 MSC,Raleigh,,NC 27699-161 1
13b.Disinfection type: HTH Amount: 24 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i