GW1-2022-06703_Well Construction - GW1_20220712

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
4436-A 10 ft- 205 eL '
tr. fr.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-eased:.wells OR LINER if a livable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 60 ft- 6.25 in. 188 Steel
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable troll construction permits(i.e.WC,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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.:
❑Geothermal(Heating/Cooling Supply) IhResidential Water Supply(single) ft. ft. In.'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑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/GRAS'EL 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)
FROM TO DESCRIPTION(color-,hardness,soillrock e, fain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 06/24/2022 Well ID# ft. ft.
ft.
Sa.Well Location: ft. !
Mike Cloer ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Hampton Place Rd, Whittier, NC 28789 ft. ft. n� •
Physical Address,City,and Zip ft. ft.
Jackson 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 26' 21" N 83 degrees 19' 0" W 1<a" 6�A6/24/2022
6.Is(are)the well(s): 19Permanent or ❑Temporary Signature ofCertified ell Contractor Date
By signing this form,I hereby certify that the trell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PJNo I5A NCAC 02C.0100 or 15A NCAC 02C?.0200 Well Construction Standards and that a copy
If this is a repair,fill out known troll construction information and explain the nature of the oJ'lhis record has been provided to the hell otrner.
repair under#21 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 1 GW-1 is needed.'Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also aftach additional pages if necessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.)
For multiple wells list al/depths ifdijferent(example-3lCr 200'am!2@100') Submit this GW-1 within 30 days of well completion per the following:
10 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
Iftraier 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!rotary
12.Well construction method: 24c.For Water Supply and Open-Loon 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 60 Method of test: air ; '
13b.Disinfection type: HTH Amount: 9 oZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018