GW1-2023-02585_Well Construction - GW1_20230410

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
60 ft, 265 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. 82 ft. 6.25 i° SDR21 PVC
Company Name .16.INNER CASING OR TUBING eothermal closed-loa
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable,cell construction permits(i.e.C11C,County,State,Variance,ere.) 0 ft. ft. in•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single) g, ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr, 17 ft- bentonite
❑Monitoring ❑Recovery 17 fL 20 ft, bentonite
Injection Well: fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable
❑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,soil rock a rain Fim,etc.)
ft. ft.
4.Date Well(s)Completed: 03/14/2023 Well ID# ft. fr.
5a.Well Location: fr. fr.
Bob Wehr ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
440 Cross Creek, Robbinsville, NC 28771 ft. ft. APR 0 �Q73
Physical Address,City,and Zip ft. ft.
Graham 21.REMARKS :_•,. :� :mot .:
'v',a
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 21' 11" N 83 degrees 50' 5" W X-a 1/ 3/14/2023
6.Is(are)the well(s): In Permanent or ❑Temporary Signature ofCertified W Vcontractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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.
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 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: 265 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@1000
60 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
Ifwater 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 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
air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 60 Method of test:
I
13b.Disinfection type: HTH Amount: 9 OZ
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018