GW1-2021-04625_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ON '
Jeff Hyde 14.WATER ZONES
Well Contractor Name A 2�2 FROM TO DESCRIPTION
2050-A ret�aY 1 i' L 25 ft- 405 ft.
ra ,.f�ssirrg t7 slt ft. ft.
NC Well Contractor Certification Number
�rlf vl I r11pp^I c C�Y;OII 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC LnNR c FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 97 ft. 6.25 188 Steel
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑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 TO DESCRIPTION(color,hardness,soit/rock type,grain size,etc.
ft. ft. 1
4.Date Well(s)Completed: 04/16/21 Well ID# ft. ft.
ft. ft.
5a.Well Location:
Chris Green ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Impact Drive, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
35 degrees 24' 39" N 83 degrees 27' 52' W
Yy i 0`��au �al
6.Is(are)the well(s): CJPermanent or ❑Temporary Sofitu&6Ptertj d well ontractor I 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 MNo 15A NCAC 02C.0100 or 15A NCAC 02C.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 provided to the hell owner.
repair under#21 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 I GW-I 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: 405
For multiple wells list a//depths iJVierent(example-3 tt 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
25 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
IJ'water level it abo•e 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produu...r over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 3 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 18 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018