GW1-2021-04623_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor information:
Kaleb T. Hyde ® ��;` `�'���Je.+ 14.WATER ZONES
Well Contractor Name I �+ FROM TO DESCRIPTION
4436-A
250 ft. 605 ft.
P,9AY 1 'J 2021
ft. ft.
NC Well Contractor Certification Number £ ry nLeCSlflt] 5,OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC Irlic l„3 110n I CJ FROM TO DIAMETER THICKNESS MATERIAL
nSa^dtr^Y10i1 0 ft 160 ft 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING edtheir at closed-loop)
2.Well Construction Permit#: 0192 FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable we//construction permits(i.e.II/C.C'ounit State, Variance,etc.) Q ft. ft. 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) CJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Im 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 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.. TO fr. DESCRIPTION(color,hardness,soillmek type rain sin,etc.
4.Date Well(s)Completed: 04/28/2021 Well ID# ft. fr.
5a.Well Location: ft. ft.
Keith Grieser ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Luther Bingham Rd, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS
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 18' 59" N 83 degrees 35' 47" W
4/28/2021
6.Is(are)the well(s): I]Permanent or ❑Temporary Signature o�e Vl`�ll Contractor I Date
By signing this form,1 hereby certify that the we/l(.$)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been prorided to the well owner.
repair under#21 remarks section or on the back of this farm.
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-I 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: 605 (ft.)
For multiple wells list all depths ifdierent(example-3(a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
250 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
6.25 24b. For Injection Welts: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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 12 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 15 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018