GW1--02793_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde _14.WATER ZONES' 1 i
Well Contractor Name FROM. TO DESCRIPTION
100 ft. 455 ft. I I
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 t THICKNESS MATERIAL
0 ft. 140 ft. 6.25 I 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.UIC,County,State,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN, i
Water Supply Well: FROM , TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CIResidential Water Supply(single) ft. ' ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT l
❑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)
['Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
❑Aquifer Test ❑Stormwater Drainage ft. ft.
DExperimental 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 type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: 04/04/2024 Well ID# ft. ft. L,
5a.Well Location: ft. ft. f t; < o..!_ 'L_ i i 1 'l
Patricia Rhodes ft. ft. , \ ryry
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY 0 L�L r
Double Springs,Raccoon Ridge Dr.Almond, NC 28702 ft. ft. Info::.. r.P;-;-.:5 <3 vFrt
Physical Address,City,and Zip ft. ft. Lc i d t Y�Uv
Graham ,21.REMARKS . I.
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 22' 53" N 83 degrees 38' 34" W ,
/ � 4/4/2024
6.Is(are)the well(s): CJPermanent or OTemporary Signature of Certified W�IrContractor Date
By signing this form,I hereby cert fy that due well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the of-this record has been provided to the well owner.
repair under#2/remarks section or on the back of this Jorm.
23.Site diagram or additional well details:
You For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same may use the back of this page to provide additional well construction info
construction,only I 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: 455 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@a 200'and 2@l00')
24a. For All Wells: Original formto Division of Water Resources (DWR),
10.Static water level below top of casing: �� (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 I 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 departmentp of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing Over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 Method of test: air
13b.Disinfection type: HTH Amount: 18 ,
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Fonn GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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