GW1-2021-01584_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeff Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
10 rr• 105 rt.
2050-A rt. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 rt• 36 rr• 6.25 '" 188 Steel
Company Name ."
-r 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 C'N ty,State, Variance,etc.) 0
3.Well Use(check well use): ft. R, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT..SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 ft.
❑Monitoring ❑Recovery 17 it. 20 ft.
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
❑Experimental Technology ❑Subsidence Control
❑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,soi0rock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed: 02/05/2021 Well ID#
5a.Well Location: ton
rt. rt.
Chris Wiggins t` t`
Facility/Owner Name Facility ID#(if applicable)
Dehart Mill Rd, Bryson City, NC 28713 ft. ft. MAR X 9 202i
to
Physical Address,City,and Zip ft. ft. Information Prooessin Unit
Swain 21.REMARKS MAIR Section
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) n=�4
35 degrees 23' 43" N 83 degrees 29' 18" W 2/5/2021
6.Is(are)the well(s): [nPermanent or ❑Temporary Sign re o ified WellContractor- Date
By ig in t i rm,I herehy cert�that the i 11(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!]No 15 A 0 C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/fthis is a repair,fill out known well construction information and explain the nature of the oft is record has been provided to the well owner.
repair under#21 remarks section or on the back o/'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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 105 (ft.)
For multiple wells list all depths ifili ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f 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) Method of test: air
20 Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 6 oZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018