GW1-2021-06000_Well Construction - GW1_20211008

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
150 rt 405 rt.
4436-A
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for mulft-cased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 66 ft. 6.25 1 SDR21 PVC
Company Name
0478 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List al/applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wel Is>100,000 GPD FROM I TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 ft.
❑Monitoring ❑Recovery 17 ft. 20 ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, min sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 09/15/2021 Well ID# ft. ft.
Sa.Well Location: ft. ft.
Mike Leskow ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 111'
IVA
Carpenter Road, High Knob, Bryson City, NC 28713 ft. ft. ` sing ups
Physical Address,City,and Zip ft. ft �►110C1'i 31 S�vi(10n
21.REMARKS
Swain
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 21' 48" N 83 degrees 28' 16" w � 9/15/2021
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6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of(Certifiepkell Contractor I Date
Hy signing this form,1 hereby certify that the well(s)was(were)construcled 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 Consiruction Standards and that a copy
If this is a repair,.lill out known well construction information and explain the nature of the of this record has been prorided to the well owner.
repair under#21 remarks section or on the back of thus/orm.
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft.)
hor multiple welds list a//depths ifdifjerent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
150 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
baler level is above casing,use"+" k
11.Borehole diameter: 6.25 (in.) 24b. For Irkiection 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
2 air Permit Program,1611 MSC,Raleigh,�NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 12 OZ e
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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