GW1-2021-00096_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
r
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION!
4436-A 600 ft. 755 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Graham Well Drilling LLC FROM TO DIAMETER; THICKNESS MATERIAL
0 f1. 101 ft- 6.25 'in' I SDR21 PVC
Company Name
0380 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, Ilartance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) in.
❑industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Ilrl ation ❑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.SAND/GRANGE PACK if a livable
❑Aquifer Storage and Recovery OSalinity 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,soiVrocktype, rain sia,etc.)
ft. ft.
4.Date Well(s)Completed: 10/18/2021 Well ID# ft. ft.
ft. ft.
5a.Well Location:
Heidi Biederman ft. ft. �/ g
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. -
Battle Branch, Bryson City, NC 28713 ft. rt.
Physical Address,City,and Zip ft. ft.
DVVR SECTION
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 20' 37" N 83 degrees 28' 7 " W
pS/� 4 10/18/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified II Contractor Date
By signing This Jorni,1 hereby certify that the wells)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or [nNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standardv and that a copy
1J'this is a repair,fill out known well construction informaiton and explain the nature of the of this record has been provider(to the well owner.
repair under 921 remarks section or on the back of this Jbrm.
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: 755 (ft.)
For nnduple wells list all depths ifdi(ferent(example-3@200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
600 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,:Raleigh,NC 27699-1617
I f water level is above casing,use" I
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 276I 9=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
Permit Program, 1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) '25 Method of test: air ram y
13b.Disinfection type: HTH Amount: 6 oZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018