GW1-2021-04627_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ^ y
Jeff Hyde , ' 14.WATER ZONES
Well Contractor Name ppn�J 2�21 •FROM TO DESCRIPTION
2050-A 1y�H 1 L 80 ft 605 ft.
NC Well Contractor Certification Number c rnDC�Sl
U�I1 rt. ft.
-rill
r+ +ii1Lt11>? 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC I ttiv`kV-1Uydt2�s Y,O� FROM . TO DIAMETER THICKNESS MATERIAL
V 0 ft. 62 ft.
6.25 i"• SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#' FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.IHC,County,State, Variance,etc.) 0 ft. ft. ! in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in•
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT E;
❑irrigation ❑Wells>100,000 GPD FROM 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.SANDIGRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. m
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional:sheets if necessary)
❑Geothermal(Heating/Cooling Return)
TO) ❑Other(explain under#21 Remarks) ft. ft. DESCRIPTION(color,hardness,soillrock type, rain size,etc.)
4.Date Well(s)Completed: 04/02/2021 Well ID# ft. ft.
Sa.Well Location: ft. ft.
Barry Brown ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Alarka Highlands Tussahaw Circle Lot#19 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 hit/long is sufficient) 22.Certification:
35 degrees 21'49" N 83 degrees 23' 18" Wt 4/2/2021
6.Is(are)the well(s): OPermanent or ❑Temporary SiVKurWcrti&4n Well gntractor R Date
By signing this form,I hereby certift that the w•e/l(5)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (I No ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature of the ql this record has been provided to the well owner.
repair under 921 remarks section or on the bark 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifJereni(example-3@200'and 2@100')
80 24a. For All Wells: Original form W to Division of Water Resources (DR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If'waler level is above casing,use' .
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6.25 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (inJ 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 departmentof the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over.100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 24 oZ
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018