GW1--01715_Well Construction - GW1_20240315

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
I Kaleb T. Hyde Ia:WATER ZONES IL
Well Contractor Name FROM TO DESCRIPTION
60 ft• 405 ft• 1 1
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased v lel I)OR LINER(if ap licable)
Graham Well Drilling LLC FROM TO DIAMETER II THICKNESS MATERIAL
0 ft. 99 ft. 6.25 1 i"r SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C County,State,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. i I
Water Supply Well: 17.SCREEN _ _ I
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in. ' I
❑Geothermal(Heating/Cooling Supply) l Residential Water Supply(single) ft. ft. in. I I I
❑Industrial/Commercial ❑Residential Water Supply(shared) I8..GROUT 1 1I
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL) I 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)I
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. I
❑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 type grain site,etc.)
ft. ft. F I
4.Date Well(s)Completed: 0.1'/02/2024 Well ID/4ft, ft.
ft. ft.
5a.Well Location:
Clayton Homes/Duckett Job ft. ft. .
ft. ft. a ^ --,.---t
Facility/Owner Name Facility ID#(if applicable) �_
England Branch, Robbinsville, NC 28771 f` f` mn'�`''.L•- ,tzL:i
Physical Address,City,and Zip ft. ft. MAR 1 rj ,J
Graham
21.REMARKS '' I Z�Z
•;.a;ter'3.
J ;r�
County Parcel Identification No.(PIN) i DVr WO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 20'49 " N 83 degrees 45' 55" W / a.I4 I A/2/2024
6.Is(are)the well(s): 15Permanent or ❑Temporary Signature of Certified t Contractor 1 I' Date
By signing this form,I hereby certify that the ire%/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or CINo 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 of this record has been provided to the well outk'r.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a 200'and 2 a 100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 (ft•) Information Processing Unit,1617 MS ,(Raleigh,NC 27699-1617
If water 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
rotary I
12.Well construction method: i
24c.For Water Supply and Open-LoopIGeothermal 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
3 air Permit Program,1611 MSC,Raleigh,NO27699-1 6 1 1
13a.Yield(gpm) Method of test: il
13b.Disinfection type: HTH Amount: 15 OZ
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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