GW1-2021-03383_Well Construction - GW1_20210607

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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
20 ft. 1205 tr.
4436-A ft. ft.
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 ft. 60 ft 6.25 in. 188 Steel
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable hell construction permits(i.e.U1C.County,State,Variance,etc.) 0 ft. ft. !, in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER i SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) tr. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1� 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 ❑Stonnwater Drainage ft. R.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(colon hardness,soil/mck a rain sire,etc.)
ft. ft.
4.Date Well(s)Completed: 05/25/21 Well ID# ft. ft.
ft. ft.
5a.Well Location:
Lehman Coday ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. w
Coday Road, Bryson City, NC 28713 ft. ft. JUN X ? 20
Physical Address,City,and Zip
rt. ft.
Swain 21.REMARKS infunnation
DWIR Senlan
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 25' 20" N 83 degrees 28' 25" W
5/25/2021
6.Is(are)the Well(S): OPermanent or ❑Temporary Signature of Certified ell Contractor ! Date
By signing this form,!hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (!]No 15A NCAC 02C.0100 or 15A NCAC 02C.6200 Well Construction Standards and that a copy
!f this is a repair,fill out known melt construction information and explain the nature of the of this record has been provided to the well owner.
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 1 GW-I 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: 205 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 1@100')
20 24a. For All Wells: Original form�to, Division of Water Resources (DR),
!f
f water level is above casing,use Static water level below top of casing: (ft.) W
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
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) 20 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 9 OZ
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 6-6-2018
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