GW1-2022-08202_Well Construction - GW1_20220505

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 115 ft- 305 ft.
4436-A
fr. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Itcable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 90 fl- 6.25 ` in. I SDR21 PVC
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List 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 i SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri 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 applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I 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,soilimck type,gritin sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 04/13/2022 Well ID# ft. ft.
5a.Well Location: ft. ft.
NMAT Real Estate Holdings LLC ft. fr.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. �10
Lot#53 Black Bear Falls, Bryson City, NC 28713 ft. ft.
Physical Address.City,and Zip ft. ft ��I
Swain
21.REMARKS
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 25' 37" N 83 degrees 16' 15" W 4/13/2022
6.Is(are)the well(s): [lPermanent or ❑Temporary Signature ofCertitied fuel ontractor f Date
Hy signing this firm,I hereby certify that the shell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No l5A NCAC 02C.0100 or 15A NCAC 02C,.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under H21 remarks section or on the back o/"thi.s 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 attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.)
For multiple wells list all depths ifdifferem(example-3 a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
115 24a. For All Wells: Original form W to Division of Water Resources (DR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
f water level is above casing,use"
6.25 24b.For Injection Wells:Copy to`DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,INC 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) 10 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 9 OZ i
Fonn GW-I North Carolina Department of Environmental Quality-Division of WaterResources Revised 6-6-2018
i
4