GW1--01054_Well Construction - GW1_20240212

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: F
I
1.Well Contractor Information:
Kaleb T. Hyde 14.`WATER ZONES 1 I
Well Contractor Name FROM TO DESCRIPTION
10 ft. 180 ft. I 1
4436-A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 39 ft. 6.25 ; in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: • FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK',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 i .SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l lResidential Water Supply(single) ft 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 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 TO DESCRIPTION(coior,hardness,soil/rock type,grain size,etc.)
ft. ft. iI
4.Date Well(s)Completed: 01/12/2024 Well ID# ft. ft
ft. ft.
5a.Well Location: +�
James Ryan ft. ft. ,, �1-# t,. c
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Lower Mountain Creek, Robbinsville, NC 28771 ft. ft. FEB 1 2 2024
Physical Address,City,and Zip • ft. ft. )nfor tt'D tPs'Sw9.AEt+y u,..1.
Graham 21.REMARKS .. . I, . [ '{^i,r,]��
•
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 20'48" N 83 degrees 43'1" W /<a- 1/ j, 1/12/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified elf Contractor Date
By signing this form,I hereby certify that'the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CJNo 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 it formation and explain the nature of the of this record has been provided to the well owner. _
repair under a21 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: 180 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 r�i 200'and 2@/00')
24a. For All Wells: Original foim'to Division of Water Resources (DWR),
10.Static water level below top of casing: 10 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
6.25 24b.For Injection Wells:Copy to DWR,Underground injection Control(IUC)
11.Borehole diameter: (in.) 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 producing1•over 100,000 GPD:Copy to DWR,CCPCUA
30 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)
13b.Disinfection type: HTH Amount: 9 oz
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018