GW1-2022-10801_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES { I
FROM TO DESCRIPTION
Well Contractor Name
250 fr• 355 fr.
4436-A ft. ft.
iI
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. ft. 6.25 I, in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eotliermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER ! THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State, Variance,etc.) 0 ft. 96 ft. it in.
3.Well Use(check well use): ft. ft.
in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT_ r.
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 ft- bentonite
-• ❑Monitoring - -❑Recovery -- - 17 'It- 20 ft- bentonite
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
t9SAND/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).
FROM TO DESCRIPTION(color,hardness,soillrock e, nain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 1 1/22/22 Well iD# ft. ft.
ft. ft.
5a.Well Location:
Tim Mason/Buckman Job ft. ft. :
Facility/Owner Name Facility ID#(if applicable) ft. ft. i ,� '6....,' Ve 4 1{a,•
Fontana Lake Estates, Bryson City, NC 28713 ft. ft. DEC ,_;a 2022.
Physical Address,City,and Zip ft. ft. *�
Swain 21.REMARKS un,
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 22' 50" N 83 degrees 31' 37" W 'r i 11/22/2022
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Il Contractor I Date
By signing this farm,I hereby certify that the weN(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repalr,under'21 remarks section or on the back ofthis 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: 355 (ft')
For multiple wells list all depths ifdi/ferent(example-3@200'and 2 a 100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 250 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJlraterlevel is above casing,use
II.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy tojDWR,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) 20 Method of test: air
Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13b.Disinfection type: HTH Amount: 6 OZ
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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