GW1-2022-09327_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD(CW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 100 ft. 355 ft.
4436-A 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. 59 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
List all applicable well construction permits(i.e.UK',County,Stale, Variance,etc.) 0 ft. fL 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) ClResidential Water Supply(single) ft. ft. in.
❑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 ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
typ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocka main sire,etc.)
ft. ft.
4.Date Well(s)Completed: 09/29/2022 Well ID# ft. ft.
ft. ft.
5a.Well Location:
Sharon Hoffman ft. ft. - r
Facility/Owner Name Facility ID#(ifapplicable) '"'••-'
DeHart Cove Rd., Bryson City, NC 28713 ft. ft. OCT 0 7
Physical Address,City,and Zip ft. rt.
Swain 21.REMARKSi-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
35 degrees 24' 9" N 83 degrees 28' 41" W 9/29/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature ofCJrti a Well o ctor Date
By signing this firm,1 hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well, ❑Yes or CINo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
1l'thi.s is a repair,fill out known well construction information and explain the nature o/'the q this record has been provided to the well owner.
repair under=21 remarks section or on the back oJ'1his Jorm.
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:-' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 355 (ft•) Submit this GW-I within 30 days of well completion per the following:
For multiple we/Ix list all depths iJdiffereni(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 100 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJ\rater level is above casing,use"I" i
24b. For Injection Wells: Copy toj DWR, Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (in.) 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
7 air
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type. HTH Amount: 12 oZ
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S