GW1-2021-02215_Well Construction - GW1_20210721

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: s E[)
Kaleb T. Hyde ��� I4.WATER zoNEs'
Well Contractor Name ¢ FROM TO DESCRIPTION
4436-A ll�j- G 1 202� 50 ft• 405 ft.
VOj ft. rt. �
NC Well Contractor Certification Number . C0�95lftg
15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC 1n¢�`�' D�,r42 cJ��ron FROM TO DIAMETER THICKNESS MATERIAL
0 fit- 138 ft 6.25 in SDR21 PVC
Company Name _16.INNER CASING OR TUBING Ieothermal closed-loop)
2.Well Construction Permit#: 0434 FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,County,State,Variance,etc.) 0 ft. ft. ii in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
, 3
❑Irrigation ❑We]IS>100,000 GPD FROM TO MATERIAL I'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 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)
❑Geotheral(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiUrock a rain size,etc.)
ft. ft.
4.Date Well(s)Completed: 06/01/2021 well iD# ft. ft.
5a.Well Location: ft. ft.
James Guma ft. ft.
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
Galbraith Creek, Johnathan Lane, 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:
(ifwell field,one]at/long is sufficient) 22.Certification:
35 degrees 27' 49" N 83 degrees 24' 24" W
6/1/2021
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature ofCertirieVVell Contractor Date
By signing ihis.form,1 hereby certify that the'well(s)ivas(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02e,'.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ive/l construction iglbrmation and explain the nature of the of this record has been provided to the we//owner.
repair under 92I remarks section or on the back o,f 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 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdiffereni(example-3@200'and 2 a 100') 1
50 24a. For All Wells: Original form,to Division of Water Resources (DWR),
]0.Static water level below top of casing: (ft.) Information Processing Unit,16171�SC,Raleigh,NC 27699-1617
if water level is above casing,use"+"
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 over 100,000 GPD:Copy to DWR,CCPCUA
Penn it Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 5 Method of test: air Y
13b.Disinfection type: HTH Amount: 15 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources t Revised 6-6-2018
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