GW1--03488_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 100 ft. 605 fL
4436-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(1f ap licable)
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 48 ft. 6.25 in• SDR21 PVC
('ompatry 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.t/IC,County,State,Variance,etc.) 0 ft ft. in
3.Well Use(check well use): ft. ft in.
17.SCREEN
Water Supply V.I'll: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential 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 El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(cobs,hardness,soil/rock type,grain size,ea.)
ft. ft.
4.Date Well(s)Completed: 05/16/2024 Well ID# ft. ft.
ft. ft.
5a.Well Location:
Eric Penniman ft. ft. -tom'f''\ 'E r:
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
J U N 11 202*
Lower Tuskeegee, Robbinsville, NC 28771 ft. ft.
Physical Address.City,and Zip ft. ft. 1ro1iLlCisk�@ 1 f•4C lt�ti`��t F'
Graham 21.REMARKS is
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 25'43" N 83 degrees 40' 5" W /�a..6 ,/
9'Y 5/16/2024
6.Is(are)the well(s): lPermanent or ❑Temporary Signature of Certified wel `ontractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l No ISA NC'A('02C.0100 or ISA 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=21 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 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: 605 ow
For multiple wells list all depths ifdii different(example-3@200'and 2@I00� Submit this GW-1 within 30 days of well completion per the following:
100 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (k) Information Processing Unit,1617 MSC,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
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) 2 Method of test: a I r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 24oz
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018