GW1-2022-08207_Well Construction - GW1_20220505

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES r
Well Contractor Name FROM TO DESCRIPTION
40 e• 505 rr.
4436-A fr. rr.
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. 72 ft. 6.25 in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 17 rt• bentonite
❑Monitoring ❑Recovery 17 ft- 20 ft- bentonite
Injection Well:
rt. 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 fr. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soi#rock type,gmin siu,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 04/20/2022 well ID# ft. ft.
5a.Well Location: ft. ft.
Gary Rolfe ft. ft. _
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. y •P tl d i!
Lot#17 Black Bear Falls,Tree Frog Lane, Bryson City,NC 28713 ft. ft. ,
Physical Address,City,and Zip ft. ft. '
Swain 21.REMARKS v
County Parcel Identification No.(PIN) m Ozl')�e'c 71+'i1,7 1J1i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
35 degrees 25 31" N 83 degrees 16' 43" W K �
,' 4/20/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertifi Vwell Contractor I Date
Hy.signing this form,l hereby cerl jJ that the wel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lj'ihis is a repair,Jill out known well construction information and explain the nature of the of litis record has been provided to the well oit ner.
repair under R21 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 attach additional pages if necessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft.) Submit this GW-1 within 30 days of well completion per the following:
leor multiple wells list all depilts ifdii ferent(example-3@200'and 1@100')
40 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
/fwaler 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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 21 oz40
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i
I