GW1-2021-06001_Well Construction - GW1_20211008

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
20 ft. 805 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 110 ft 6.25 ! 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.UIC,County,State,variance,etc) 0 ft. fL I, in.
3.Well Use(check well use): ft. fr. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IhResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation []We]Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 7 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 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,soiUrock type nin sin,etc.)
4.Date Well(s)Completed: 09/01/2021 Well ID# ft. ft.
Sa.Well Location: ft. ft.
MY
Jeff Hyatt ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
504 Cline Road, Bryson City, NC 28713 ft. ft. l 1 Unit
Physical Address,City,and Zip
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
35 degrees 27' 14" N 83 degrees 24'46" W
u i 9/1/2021
6.Is(are)the well(s): PJPermanent or ❑Temporary Signature ofCertifie ell Contractor Date
By signing this/orm,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 15A NCAC 02C.0100 or 15A NCAC 02C i0200 Well Construction Standards and that a copy
If this is a repair,fill out knoum well construction information and explain the nature of the oJl'his record has been provided to the well owner.
repair under 921 remarks section or on the back ofthis.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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 805 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferem(example-3@200'and 2 et!00')
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
ff water 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-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
13a.Yield(gpm) '5 Method of test: air
Permit Program, 1611 MSC,Raleigh,iNC 27699-1611
13b.Disinfection type: HTH Amount: 36 oZ
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
u
i
f
I