GW1-2022-01747_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KalebT. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. dry well
4436-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR'.L1NER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 94 ft. 6.25 in SDR21 PVC
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.U1C,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) LiResidential Water Supply(single) ft. ft. in.
❑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 EMPLACEMENTMETHOD
❑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)
TO) ❑Other(explain under#21 Remarks) fr. it. DESCRIPTION(color,hardness,soil/rock type, rain save,etc.)
4.Date Well(s)Completed: 1/2/22 Well ID# ft. ft.
ft. ft.
5a.Well Location:
Tom Thayer ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. � n
Fontana Lake Estates Hemlock Ridge, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 22' 58" N 83 degrees 32' 4" W Aa-
1/2/2022
6.Is(are)the well(s): [tPermanent or ❑Temporary Signature of Certified r
Contractor Date
By signing this form,I hereby certify that the mel/(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: - ❑Yes or In No 15A.NCAC 02C.0100 or 15A NC AC 01C.0200 Well Construction Standards and that a copy
IJ7his is a repair,fill out known well construction information and explain the nature of the gfthis record has been provided to the well owner.
repair under d'21 remarks section or on the back gf 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 into
construction,only 1 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: 630 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ij'dii ferem(example-3@200'and 2@100')
dry well 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
1f hater level is above casing use
6.25 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,etc.) county environmental health depart Ii ent 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) 0 Method of test: air
Pennit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 0
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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