GW1-2022-09322_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
4436-A 300 ft. 705 ft.
ft. 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. 34 fit- 6.25 SDR21 PVC
Company Name 16.INNER CASING OR TUBING fileothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER I 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) ft. ft. in. I
❑Industrial/Commercial ❑Residential Water Supply(shared) lg,GROUT
❑Irrigation ❑Wel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 fit- bentonite
❑Monitoring ❑Recovery 17 fit- 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 ❑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 To DESCRIPTION(color,hardness.soiBrock a rain size,etc.)
tt. ft.
4.Date Well(s)Completed: 09/02/2022 well ID# ft. ft.
Sa.Well Location: ft. ft.
Mountain Vista Builders/Alan Parcell ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Fontana Ridge, Bryson City, NC 28713 ft. ft. t
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 lat/long is sufficient) 22.Certification:
35 degrees 25' 21" N 83 degrees 29' 31" W, &a" 1/ I 9/2/2022
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified We ontractor Date
By signing this form,1 hereby certify that the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or It No 15A NCAC 01C.0100 or 15A NC AC 02C,.0200 Well Construction Standards and that a copy
//'this is a repair,fill out known well construction information and explain the nature oJ7he of this record has been provided to the well oumer.
repair under k21 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: 705 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2 td100')
300 24a. For All Wells: Original form to Division of Water Resources (DWR),
If voter level is above casing,use"+"
10,Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells:Copy to IDWR,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) '75 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 18 OZ
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018