GW1-2021-00502_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeff Hyde 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
680 fL 1805 ft.
2050-A fL fL
NC Well Contractor Certification Number 15.OUTER CASING for molti-cased wells OR LINER if a licable
Graham Well Drilling LLC FROM To DIAMETER TJUMES MATERIAL
0 fL 68 fL 6.25 1° 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.UIC,County,State,Variance,etc.) 0 fL ft. in.
3.Well Use(check well use): ft. fL Iin
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in
❑Geothermal(Heating/Cooling Supply) ItResidential Water Supply(single) fL fL in.
❑industrial/Commercial ❑Residential Water Supply(shared) M GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 17 fL
❑Monitoring ❑Recovery 17 fL 20 fL
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothemtal(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 sin,etc.
ft. fL
4.Date Well(s)Completed: 01/20/2021 well ID# fL It.
fL fL
5a.Well Location:
Fontana Lake Builders fL ft.
Facility/Owner Name Facility ID#(if applicable) fL fL
Rock Ledge Lot#10, Hwy 19 Ela, Bryson City, NC 28713 fL ft.
Physical Address,City,and zip k R
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification:
35 degrees 21' 16" N 83 degrees 35'4" W 1/25/2021
nreAell Cactor Date
6.Is(are)the well(s): t•JPermanent or ❑Temporary Sig k
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 ONo 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 421 remarks section or on the back of this form. a ""71
23-Site.diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havi'ng`tlf'said 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 q(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: F Cfj 4�UB MTITAL INSTRUCTIONS
9.Total well depth below land surface: 805 (ft),, i I '`: i
For multiple wells list all depths ifdtfferent(example-3 a200'and 1(C 99 i Submit this W-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 680 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: 6.25 (ia) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.,EorW-ate"upR13'�ar►d O.ReneLnpl►GeothermaLRetutn Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departmOnt 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) •25 Method of test: air
Permit Program,1611 MSC,Raleigh;NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 6 oZ
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018