GW1-2022-01746_Well Construction - GW1_20220207

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
200 ft, 705 ft.
4436-A
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casediwells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 77 ft- 6.25 i" SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,Slate,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.
❑Geothennal(Heating/Cooling Supply) IlResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wel Is>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 a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothenn FROM TO al(Heating/Cooling Retum) ❑Other(explain tinder#21 Remarks) ft. ft. DESCRIPTION(color,hardness,soil rock type, rain sin,etc.)
4.Date Well(s)Completed: 01/26/2022 well ID# ft. ft.
ft. ft.
5a.Well Location:
Phillip Carson
ft. ft. r^ 6"
Facility/Owner Name Facility ID#(ifapplicable) ^7 ° •+ P.
Carson Farm Road, Bryson City, NC 28713 f` ft. FEB 0 7 9
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS I o + {s)[i�
County Parcel Identification No.(PIN) W� , 'I r " X fir`�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 26' 23" N 83 degrees 29' 54" W K � 1/26/2022
6.Is(are)the well(s): In Permanent or ❑Temporary Signature of Certified I Contractor ! Date
By signing thi.s.(orm,1 hereby certify that the we/1(s)Was(Were)constructed in accordance With
7.Is this a repair to an existing well: ❑Yes or 11No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/fihis is a repair,fill out known well construction infornialion and explain the nature of the of this record has been provided to the Well ou-ner.
repair under`.21 remarks.seclion or oil the back of this fn-ni.
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 705 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For mulliple Wells list all depths ifdifferent(example-3 a 200'and 2 rr 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 200 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is abo•e casing,use"�"
625 24b. For Infection Wells: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,eta.) 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) '25 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type. HTH Amount: 24 oZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018