GW1-2022-06923_Well Construction - GW1_20220603

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
140 ft- 305 ft.
4436-A
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
0 ft• 122 ft. 6.25 in. I SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well constructton pernuis(i.e.111C,County,State, Variance,etc.) 0 ft. I ft. in.
3.Well Use(check well use): ft. I fr. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr. 17 fit- 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 ❑Stonmvater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(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 421 Remarks) fr. ft.
rt. ft.
4.Date Well 05/02/2022 s)Completed: Well ID#
5a.Well Location: ft. ft.
Debbie Tertinger fr. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. W,MA" 1 �t+tl tN3^ lx�j
Double Spring, Whitetail Ridge Dr. Almond, NC 28702 ft. ;r, ;ti iti r 1`l
Physical Address,City,and Zip ft. ft.
Graham 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lal/long is sufficient) 22.Certification:
35 degrees 22' 37" N 83 degrees 38' 43" W Xa-" Y" 5/2/2022
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified W Contractor Date
By signing this./brni,1 hereby cerlf�Thal the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and thal a copy
If this is a repair,fill oul known well construction it jbrmation and explain the nature oJ'lhe of this record has been provided to the well owner.
repair under#21 remarks section or on the back oJ7his 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-I 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: 305 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiJJereni(example-3 ct 100'and 2@100')
140 24a. For All Wells: Original form to Division of Water Resources (DWR),
1 Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lflrater 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
13a.Yield(gpm) 25 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 2 7699-1 6 1 1
13b.Disinfection type: HTH Amount: 9 oZ
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018