GW1-2022-09326_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
75 ff. 305 ft.
4436-A
e. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multAcased wells OR LINER if a livable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 104 ft• 6.25 'in SDR21 PVC
Company Name 16:INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lief all applicable well construction permits(i.e.WC,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) CJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT t
❑Irri anon ❑Wel Is>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 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) ft. TO fr. DESCRIPTION(color,hardness,soiUrock type, amin size.etc.)
4.Date Well(s)Completed: 09/27/2022 Well ID# ft. ft.
5a.Well Location: rt. ft.
Michael Green/Caleb Williamson ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. �., _
Trent Field Road, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS
, .. .. j
County Parcel Identification No.(PIN) _,•,i'; -,'•ti-:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 24' 10" N 83 degrees 29' 2" N
�'�� 9/27/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertified Well Co actor Date
By signing this fornt,1 herehy certify that the hell(,)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC'02C 10200 Well Construction Standards and that a copy
1J'thi.s is a repair,Jill out known it-ell construction inl6munion and explain the nature q/'the 4f this record has been provided to the well owner.
repair under=21 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 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: 305 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths i1'diljerent(example-3@200'and 2@100')
75 24a. For All Wells: Original form to Division of Water Resources (DWR),
j Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJlrater level is above casing,use"*"
6.25 24b. For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 271699-1636
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) 6 Method of test: air
Permit Program, 1611 MSC,Raleigh';NC 27699-I611
13b.Disinfection type: HTH Amount: 9 oz
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-2018