GW1-2021-00192_Well Construction - GW1_20211213

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
5 ft. 605 fr.
4436-A
fr. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased,wolls OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 rt• 117 rt• 6.25 in. 1813 Steel
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,Stale, Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. ft. in.I
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑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.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fr.
❑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,soil/rocka gain size,etc.)
ft. ft.
4.Date Well(s)Completed: 1 1/24/21 Well ID#
-
5a.Well Location:
Andrews Construction/Jerry and Sue Seely Job ft. ft. '
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Tobacco Branch Rd, Almond, NC 28702
Physical Address,City,and Zip ft. ft.
Graham 2L REMARKS iitl
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 23' 6" N 83 degrees 38' 33" W &a," f/,,,,dn 11/24/2021
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature ofCertifie �ell"Contractor Date
By signing this form,I hereby certify that the irell(s)war(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or OND 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature o(the of this record has been provided to the well owner.
repair under il2l remarks section or on the back q0his.16rm.
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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:-' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft)
For multiple wells list all depths t(differem(example-3@200'and 2@100') Submit this GW-1 within 30 days Of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is abo+e casing,use"--
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells: Copy toDWR,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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1.5 Method of test: air
Permit Program,1611 MSC,Raleigh,;NC 27699-1611
13b.Disinfection type: HTH Amount: 27 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources it Revised 6-6-2018