GW1-2022-06410_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(CW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4436-A 600 ft- 855 ft.
ft. 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
Company Name
0 ft. 100 ft- 6.25 ' in SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Li.sl 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 1. SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) ft• ft. in.l
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr. 17 ft- bentonite
❑Monitoring ❑Recovery 17 ft. 20 ft. bentonite
Injection Well:
ft. fr.
❑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. ft.TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
4.Date Well(s)Completed: 05/12/22 well lD# ft. ft.
5a.Well Location: ft. ft.
Bill Bohl ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Unahala Creek, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS
rl'lASii '111�,P s
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 21' 29" N 83 degrees 22' 41" W
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified VContractor Date
By signing this form,l hereby certify that the hell(+)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
//'this is a repair,fill out known well construction inJi)rniation and explain the nature oJ'the of this record has been provided to the well owner.
repair under ii2l remarks section or on the back ot'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 1 GW-I 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: 855 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths t/dJjerent(example-3 rr 200'and 1@100')
600 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
lf'waler 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
1 13a.Yield(gpm) Method of test: air Permit Program, 1611 MSC,Raleigh,INC 27699-1611
13b.Disinfection type: HTH Amount: 12 OZ
i
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources ` Revised 6-6-2018