GW1-2022-03913_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
65 rt• 605 a.
4436-A
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 88 fr. 6.25 I in SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(IIC.Counl,Slale, 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) I'Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supplv(shared) 18.GROUT
❑irrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 17 ft. bentonite
❑Monitoring ❑Recovery 17 ft- 20 ft- bentonite
Injection Well:
ft. rt.
❑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,grain sire,etc.)
4.Date Well(s)Completed: 03/08/2022 Well ID# ft. ft.
ft. ft.
5a.Well Location:
Ted Duncan
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. I a" ,:
Hyde Place Drive, Bryson City, NC 28713 ft. f`•
Physical Address,City,and Zip ft. ft.
2 Zan
Swain 21.REMARKS
County Parcel Identification No.(PIN)
UM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 25' 53" N 83 degrees 28' 53" W
3/8/2022
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature ofCerti fie well Contractor Date
By signing this forth,I hereby cerlify that llte we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02CI.0200 Well Construction Standards and that a copy
(/'this is a repair,Jill out known well construction u formation and explain the nature of the o/7his record has been provided to the well owner.
repair under°2l remarks section or on the back gJ7his farm.
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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft.)
For multiple wells list al/depths iJ'dt/Jereni(example-3 c(7i 200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
65 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'
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells:Copy to iDWR,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: j
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1.5 Method of test: air
Permit Program, 1611 MSC,Raleigh NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 24 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018