GW1--04738_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
e FROM TO DESCRIPTION
Well Contractor Name
50 ft. 305 ft.
4436-A ft. ft.
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' 118 ft- 6.25 in' SDR21 PVC
Company Nana 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.(/IC,County,State,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.St KEEN
Water Supply Well: t•RO't TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AM01 NT
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 OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storrnwater 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(color,hardness,soil rock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: 07/11/2024 well ID# ft. fL
ft. ft.
5a.Well Location:
Kerr Cable ft. ft. L. < r
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Hwy 28 Almond, NC 28702 ft. ft. - AUG l 2 7"
Physical Address,City,and Zip ft. ft.
Graham 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 22' 34" N 83 degrees 39' 51" N v � L/
/ yy 7/11/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified W Contractor Date
By signing this form,1 hereby certify that the well was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 1SA N(A('02C.0100 or 15A NCA('02C.0200 Well Construction Standards and that a copy
If this isa repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair umler 2l remarks section or on the hack 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3@200'and 2@l00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 50 (R•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
/fwater level is above casing,use" "
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 18 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13h.Disinfection type: HTH Amount: 12 oz
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018