GW1-2022-03318_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
80 ft. 605 ft.
4436-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells IN OR LER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 75 ft- 6.25 ! i" SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction pennil.s(t.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 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. j
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT i
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 ft, bentonite
❑Monitoring ❑Recovery 17 ft. 20 ft. bentonite
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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. TO ft. DESCRIPTION(color,hardness,soil/rock type i2in size,etc.)
4.Date Well(s)Completed: 02/11/2022 Well ID# ft. ft.
5a.Well Location:
Rob Loafman ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
Thomas Divide, Brsyon City, NC 28713 ft. it.
MAR 14 Physical Address,City,and Zip 7
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 28' 24" N 83 degrees 24' 7" W 2/11/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertifted Wevbfltractor Date
l
By signing!hiss Jorm,1 hereby cerlify that the urell(c)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!No 15A NCAC 02C.0100 or 15A NCAC 02('10200 Well Construclion Standards and that a copy
U this is a repair,Jill out known well construction information and explain the nature oJ7he of this record has been provided to the well ou ner.
repair under-21 remarks section or on the back oflhis 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:--'- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft.)
For multiple wells list all depths tf ditferent(example-3 a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
80 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfi Static water level below top of casing: (ft.) Information Processing Unit,1617 MtSC,Raleigh,NC 27699-1617
Jlvater 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 27,699-1636
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 o er 100,000 GPD:Copy to DWR,CCPCUA
75 air Permit Program, 1611 MSC,Raleigh`NC 27699-1611
13a.Yield(gpm) Method of test: i
13b.Disinfection type: HTH Amount: 24 oZ
i
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018