GW1-2023-00578_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES I!
Well Contractor Name FROM TO DESCRIPTION
400 ft- 655 ft.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased'we]is OR LiNER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 50 ft. 6.25 , in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable we//consintction permits(<.e.UIC,County,Slate,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in."
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.I
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Inigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 ft- bentonite
❑Monitoring ❑Recovery. _ 17 _fr, 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 fr. ft.
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attachadditional sheets ifnecessary)
❑Geothermal(Heating/Cooling Return) El FROM TO Other(explain under#21 Remarks) fr. ft. DESCRIPTION(color,hardness,soillrock type, min site,etc,)
4.Date Well 12/1/22 s)Completed: Well ID# ft. ft. i iF"�.,it -E__: �;'f � i=-•2 ;
ft. ft.
5a.Well Location: n/
Ken McComas ft. ft. N A ® Q 2l'L
Facility/Owner Name Facility lD#(if applicable) ft. ft. /11
Hickory Cove/Hickory Springs Trail, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 19' 1" N 83 degrees 28' 24" W 12/1/2022
Alz"
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified W t Contractor I Date
By signing this form,i hereby certify chat the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I lNo 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
1J'ihis is a repair,fill out known tire//constructioh.infonna,ion and zrplain the nature oJ'ihe of(liis record has been provided to rite well ou-ne+.
repair under 921 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 655 (ft.) I
For multiple wells list all depths iftli Brent(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
400 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifivaler level is above casing,use
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 'er 100,000 GPM Copy to DWR,CCPCUA
13a.Yield(gpm) 'S Method of.test: air
Permit Program,1611 MSC,Raleigh',NC 27699-1611
13b.Disinfection type: HTH Amount: 12 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018