GW1-2021-03532_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
30 ft. 180 fr.
4436-A fr. fr.
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
p ft. 63 ft 6.25 ' i" 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.UK',County,State, Variance,etc.) p ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO I DIAMETER II SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr. 17 ft.
❑Monitoring ❑Recovery 17 ft.. 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
ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑ FROM Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. TO ft. DESCRIPTION(color,hardness,soillrock type, rain size,etc.)
4.Date Well(s)Completed: 05/27/21 Well ID# ft. fr.
5a.Well Location: et. fr.
Ed Laney ft. ft. t�, y-
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Buckner Branch, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft' ft.
Swain 21.REMARKS information MMUSSillY
c
County Parcel Identification No.(PIN) ! 13VV�d.�i$C11vn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 25' 23" N 83 degrees 28' 38" W 5/27/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertif ed I Contractor Date
i,
By signing this form,I hereby certify that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 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 qf the oJ'this record has been provided to the well corner.
repair under 921 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 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 180 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiereni(example-3@200'and 2@100')
30 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 M IC,I Raleigh,NC 27699-1617
if water level is above casing,use"+"
ll.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 departmei t 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) 3 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 6 oZ
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources 'I Revised 6-6-2018
I