GW1--06839_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:I.Well Contractor Information: 1
Kaleb T. Hyde 14.WATER ZONES f
Well Contractor Name FROM TO DESCRIPTION
50 ft. 155 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. 96 ft. 6.25 ' 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.(I/C,County,State,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l 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.
DAquifer Recharge ❑Groundwater Remediation 19s SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additionalsheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft.
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4.Date Well(s)Completed: 10/04/2024 Well ID# ft. ft.
5a.Well Location: ft. ft.
Simon Pugh ft. ft. ..
Facility/Owner Name Facility 1D#(if applicable) ft. ft. t a .s ,-,i
Tuskeegee, Robbinsville, NC 28771 ft. ft. .
Physical Address,City,and Zip ft. ft. ! NOV •' 2024
Graham 21.REMARKS 1' , .._
County Parcel Identification No.(PIN) D_•;i. <<�;::i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 24' 19" N 83 degrees 43' 31" W / A �� 10/4/2024
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified Wel ontracIor I 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 InNo 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 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 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: 155 (ft.) Submit this GW-1 within 30 days,of,well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
50 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"+"
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (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
30 air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection.type: HTH Amount: 6 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 6-6-2018