GW1--03933_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FRONT TO DESCRIPTION
Well Contractor Name 65 ft. 505 ft.
4436-A
fr. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAIIIETER THICKNESS MATERIAL
0 f1. 123 ft• 6.25 i" SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ire//construction permits(i.e.111C Countyy,State,I'ariance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
f7lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑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 lt. bentonite
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRONT TO MATERIAL EMPLACEMENT PIETHOD
❑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. To ft. DESCRIPTION(color,hardness,soflhvcktype,grain sin,etc.)
4.Date Well(s)Completed: 05/17/2023 Well ID# fr. ft. MA 77 M.r..--�
ft. ft. 4 a... �� Y vim. a d
5a.Well Location:
Smokey Mtn Cabin Builders ft. fr. IUN 1 2J 2023
Facility/Owner Name Facility IDN(if applicable)
e.
Tasali Point, Fontana Lake Estates, Bryson City, NC 28713 e. fr. In 0f,Tr«
fY Y �A ^
Physical Address,City,and Zip
Swain 21.REMARKS
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 23'45" N 83 degrees 34' 0" W 5/17/2023
6.Is(are)the well(s): [nPermanent or ❑Temporary Signature of Certified Wel ontractor Date
By signing thisJ6rm,1 hereby cerlo that the well(i)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
ll'this is a repair,Jill au known well construction itJormation and explain the nature oJ'the ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back q('11 is Jori n.
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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For nmltiple wells list all depths ifdierent(example-3@200'and tea 100�
65 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ljwa[er level is above casing,use"+"
I I.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) 3 Method of test: ale
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 21 OZ
i
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018