GW1-2022-09959_Well Construction - GW1_20221104

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: {,
Kaleb T. Hyde 14.WATER ZONES I I.
FROM TO DESCRIPTION
Well Contractor Name 400 ft- 608 ft.
4436-A ft. ft. i
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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 69 ff 6.25 1 in SDR21 PVC
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well COnStruetl0n Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare,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) nResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _ .. .. . 1 1 ._
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 '1' 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) FROM To DESCRIPTION(color,hardness,soilhrock a grain size,etc.)
ft. ft. �
4.Date Well(s)Completed: 10/13/2022 Well ID# ft. ft.
ft. ft. I'
5a.Well Location:
Fontana Trace Associates ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Fontana Trace, Walnut Gap Rd, Bryson City, NC 28713 fr. ft. R D�••.,S 71'
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS I.
County Parcel Identification No.(PIN)
i flivsp ttJ.,:�i � s•��:`�rr;::;.1 • R::
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: i
35 degrees 23' 7" N 83 degrees 35' 30" W xa" 10/13/2022
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified rI Contractor I Date
By signing this form,I hereby certify that the u:ell(s)was(were)constructed in accordance with
7.IS this a repair to an existing well ❑Yes Or L'JNo 15A NCAC 02C:.0100 or 15A NCAC 02C i0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under e21 remarks section or on the hack 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: 608 Submit this GW-1 within 30 days of well completion per the following:
ror multiple wells list all depths ifdierent(example-3@200'and 2@100)
24a. For All Wells: Original forrr W i to Division of Water Resources (DR);
10.Static water level below top of casing: 400 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 '
IJ'waler 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 27�699-1636
12.Well construction method: rotary 24c.For Water Supply and Open-L'oop 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 o�e 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,'NC 27699-1611
13a.Yield(gpm) '25 Method of test: alr �
13b.Disinfection type: HTH Amount: 9 OZ
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Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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