GW1-2022-08800_Well Construction - GW1_20220909

i
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 60 ft. 405 ff
4436-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased w LIN ells OR ER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 47 ft. 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eotherroal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable uvell construction permits 6.e.l/IC,County,State, Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): tt. ft. in.
17.SCREEN
Water Supply Well
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) LhResidential Water Supply(single) ft. ft. in. I
❑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 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
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
ft.
4.Date Well(s)Completed: 08/04/2022 Well ID# ft. ft. _
r�
''
5a.Well Location: ft. ft. �r"Lz e iV°IT
Jeff Hennessy ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
189 Mountain Side Drive, Bryson City, NC 28713 ft. ft. In€cr inn PMw�=Rkj UnA
Physical Address,City,and Zip ft. ft. 73 16
JIJ
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 23' 49" N 83 degrees 31'3 N
AaA� 8/4/2022
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified We ontractorr Date
By signing this form,!hereby certify that the use/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (tNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
!J'this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ire//owner.
repair under#21 remarks section or on the back of 1his form.
23.Site diagram or additional well details:
S.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: 405 (ft.)
For multiple wells list all depths iJ'dii ferent(example-3 c1 00'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
60 24a. For All Wells: Original form to Division of Water Resources (DWR),
s 1 Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!J'rater level it 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 producingiover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 161 1 MSC,Raleigh,NC 27699-161 I
13a.Yield(gpm) 2 Method of test: air I
13b.Disinfection type: HTH Amount: 15 oZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018