GW1-2022-07395_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KalebT. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4436-A 50 ft. 255 ft.
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% 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. 92 ft- 6.25 in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#• FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable hell 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 I
FROM TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑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. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater 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)
TO DESCRIPTION(color,hardness,soil/rock e, main size,etc.)) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 07/27/22 Well ID# ft. ft.
5a.Well Location: ft. ft. ..s a
Brandi Hollifield
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
Stone Pile Gap Rd, Galbraith Creek, Bryson City, NC 28713 ft. ft. '� -•.';:,
Physical Address,City,and Zip ft. ft -t 1;t0
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 28' 3" N 83 degrees 24' 40" W x-a" 7/27/2022
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature ofCertified W&4f Contractor Date-
Bysigning this form,1 hereby certify that the we//(v)was(were)constructed in accordance wish
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/)'this is a repair,fill out known well construction in/iirmation and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back oJ'thir 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 255 (ft.)
Fbr multiple we/Ls list a//depths ifd�ereni(example-3 r200'and 2 a)100') Submit this GW-1 within 30 days of well completion per the following:
rj0 24a. For All Wells: Original form to Division of Water Resources (DR),
10.Static water level below top of casing: (ft.) W
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If wafer level is above casing,use"1"
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) 45 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount: 9 oZ
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018