GW1-2021-02170_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: y
Kaleb T. HydeCF
Ay 14.WATER ZONES
�� FROM TO DESCRIPTION
Well Contractor Name
4436-A J 1 JL 'L 1 2021 70 ft- 280 ft-
ft. ft.
NC Well Contractor Certification Number S81n0 Unit 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLOnio�m3tt0V proof on
:� FROM TO DIAMETER THICKNESS MATERIAL
g 0\111R Se" 0 ft. 73 rt- 6.25 in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//construction permits(i.e.UIC,County,State,l'arianee,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) [']Residential 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 a licable
❑Aquifer Storage and Recovery ❑Salinity 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)
FROM TO DESCRIPTION(color,hardness,soil/mck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 06/30/2021 Well ID# ft. ft.
5a.Well Location: ft. ft.
Bob Von Itter rt. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Everett Jenkins.Rd, Lower Stecoah, Robbinsville, NC 28771 ft. ft.
Physical Address,City,and Zip ft. ft.
Graham 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22.Certification:
35 degrees 23' 52" N 83 degrees 41' 1" W
6/30/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified We}e ontractor f Date
By signing this farm,I 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 Standards and that a copy
if this is a repair,fill out knot m well construction information and explain the nature of the of This record has been provided to the well oioner.
repair under_#21 remarks section or on the back 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: 280 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifjereni(example-3@200'and 1@100') i
70 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
Ifwaier 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 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 i ver 100,600 GPD:Copy to DWR,CCPCUA
m Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) 4 Method of test: air ,
13b.Disinfection type: HTH Amount: 9 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources. i Revised 6-6-2018