GW1-2021-02214_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name a FROM TO DESCRIPTION
� � 125 ft. 280 ft.
4436-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells O
1 ft. ft.
Graham Well Drilling LLC 'U� 1 202 0�1k RLINER if a" licable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name CCW� 0 ft. 36 ft- 6.25 ' i"• SDR21 PVC
0372 $3`�',3�^'� Qc�r�,>Jn 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: �� `J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IlResidential 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. i
❑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 I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionalsheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiu,»ck e a size,etc.)
ft. ft.
4.Date Well(s)Completed: 06/04/2021 Well ID# ft. ft.
5a.Well Location: fr. ft.
Bill Garvin ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Breedlove Road, Bryson Gap Preserve, 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 24' 38" N 83 degrees 26' 22" W
u , 6/4/2021
6.Is(are)the well(s)• In Permanent or ❑Temporary Signature ofCertifie ell Contractor { Date
By signing this form,l hereby certtry thatithe wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
//'this is a repair,fill out known well construction information and explain the nature of the oJ7his record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 dayslof well completion per the following:
For multiple wells list all depths ifdijj&rent(example-3@200'and 2@100')
125 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
//'water level is above casing,use
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary i
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 45 Method of test: air i
13b.Disinfection type. HTH Amount: 6 OZ
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Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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