GW1--03258_Well Construction - GW1_20230511

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KalebT. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
15 ft. 180 ft.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Graham Well Drilling LLC
0 f1. 144 ft- 6.25 in 188 Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//construction permits(i.e.U/C,County.State,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT i.
❑Irrigation ❑Wells>100,000 GPD FROM 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 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 ft. ft.To DESCRIPTION(color,hardness,soillrock type rain site,etc.)
4.Date Well(s)Completed: 4/6/2023 Well ID# ft. ft.
ft. ft. .e �a9 " 0� '..✓�
5a.Well Location: r-71
Scott Hyde ft. ft. s.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. M
Lower Stecoah, Robbinsville, NC 28771 ft. ft. ?r:,,N ; g UMA
Physical Address,City,and Zip ft. ft.
Graham 21.REMARKS
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 22' 27" N 83 degrees 40' 53" W
&a-," � 4/6/2023
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby certify that the�mell(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (INo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known ire/1 construction information and explain the nature of the ofthis record has been provided to the ire/1 owner.
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: 180 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple melts list all depths ifdfJferent(example-3@200'and 2 a 100')
15 24a. For All Wells: Original form to Division of Water Resources (DWR),
fti Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If maser 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
13a.Yield(gpm) 18 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 6 oZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018