GW1-2021-02216_Well Construction - GW1_20210721

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor NamEINJ
e t� FROM TO DESCRIPTION
4436-A C� !0 3o ft 655 ft•
q ft. ft.
NC Well Contractor Certification Number +� ZO L�
11 I` 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC OlI FROM TO DIAMETER THICKNESS MATERIAL
; 4 s V 0 ft- 36 ft- 6.25 i" SDR21 PVC
Company Name 1f1ICiC''3t9 NI On 16.INNER CASING OR TUBING eother at 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! SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) [nResidentiai Water Supply(single) ft. ft. in.,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wel 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.
❑Geothemtal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. TO
4.Date Well(s)Completed: 06/23/2021 Well ID# ft. ft.
5a.Well Location: ft. ft.
Cherokee Enterprises/Dollar General
ft. ft.
Facility/Owner Name Facility IDN(if applicable)
ft. ft.
West Swain, 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]at/long is sufficient) 22.Certification:
35 degrees 22' 27" N 83 degrees 31' 56" W
x' � 6/23/2021
6,Is(are)the well(s): nPermanent or ❑Temporary Signature of Certifi ell Contractor I Date
/ By signing this form,I hereby certify ihat the'irell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (INo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ol'the of This record has been provided to the well oumer.
repair under k2/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 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: 655 (ft)
For multiple wells list all depths ifdifferem(example-3@200'and 1@100') Submit this GW-1 within 30 days of well completion per the following:
30 24a. For All Wells: Original form!to Division of Water Resources (DR),
10.Static water level below top of casing: W
(ft.) Information Processing Unit,1617 MSC,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 producin> ver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 2 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 27 oZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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