GW1--06066_Well Construction - GW1_20241011

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES i
FROM TO DESCRIPTION
Well Contractor Name 200 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 I THICKNESS MATERIAL -
0 ft. 30 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.U/C,County,State,Variance,etc) 0 ft. ft. ( in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN Ji ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.•
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) J
18.GROUT Ik p...
❑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
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. .
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type grain size,etc.)
ft. ft. I
4.Date Well(s)Completed: 09/09/2024 Well ID# ft. ft. 1,
' ft. ft.
5a.Well Location: _
John Pokorny ft. ft. i.
.,: fix. i;".•,
Facility/Owner Name Facility ID#(if applicable) ft. ft. I.
Rye Field Rd, Hidden Falls, Robbinsville, NC 28771 ft. ft. OCT i 1 ZCZ4
Physical Address,City,and Zip ft. ft. F: ,_f.71 ?-. :,,
Graham 21.REMARKS 1':4,, , ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
35 degrees 22' 14" N 83 degrees 49'42" W . / � J/ 1 9/9/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified We ontractor et Date
By signing this form,I hereby certify that the u'el(s)hras(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C 10200 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 ohi'ner.
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 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 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple we//.s list all depths if different(example-3@200'and 2@100)
200 24a. For All Wells: Original form•.to 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"+"
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 J
12.Well construction method: 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
9 air Permit Program,1611 MSC,Raleigh,iNC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 6 OZ
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018