GW1-2022-07397_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES p
Well Contractor Name FROM TO DESCRIPTION
75 rt• 205 ft.
4436-A
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased'wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 184 ft- 6.25 in. 1 SS Steel
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well c•onstruc•tion permits(i.e.I/lC,County,State,Variance,etc.) 0 ft. ft. in.
in.ft.
3.Well Use(check well use): ft. l
17.SCREEN
Water Supply Well: is
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.l
❑Geothermal(Heating/Cooling Supply) (IResidential Water Supply(single) ff ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 1- 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 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 rain size,etc.)
4.Date Well(s)Completed: 07/19/22 Well ID# ft. ft.
5a.Well Location: ft. ft. �. S
Richard Bowman
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. Z'
Galbraith Creek, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft
.Swain 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 27' 33" N 83 degrees 24' 27" w
X_a,�" � 7/19/2022
6.Is(are)thewell(s): InPermanent or ❑Temporary Signature of Certified Well C tractor Date
By signing this form,l hereby certify that the ire/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or DNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f'lhis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under=21 rentarks 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (R•) Submit this GW-1 within 30 days�f well completion per the following:
For multiple wells list all depths iftli ferent(example-3 rr 200'and 2 a@100')
75 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
ljwater Jere/is above casing use"+" i
24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (in.)
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) 40 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 6 oZ
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018