GW1-2021-04624_Well Construction - GW1_20210510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeff Hyde t� 1'"' 14.WATER ZONES
Well Contractor Name v FROM TO DESCRIPTION
2050-A 2021 ft. ft.
NC Well Contractor Certification Number �y1 A 1. ry 1 , 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
Graham Well Drilling LLC 7('-CEOssl k:J v�j11 FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 97 ft. 6.25 in SDR21 PVC
Company Name It
.� y;1 sCr 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: `'vim FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc-.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: P
FROM TO DIAMETER 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
❑Irrigation ❑Wells>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:
fr. 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. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain Linder#21 Remarks) FROM ft.. To ft. DESCRIPTION(color,hardness,soiltrock type,gmin sin,etc.)
4.Date Well(s)Completed: 04/20/21 well ID# ft. ft.
ft. ft.
5a.Well Location:
Julio Ruiz ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
Happy Top Rd, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one hit/long is sufficient) 22.Certification:
35 degrees 22' 13" N 83 degrees 32' 55" w 4/20/2021
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6.Is(are)the well(s): OPermanent or ❑Temporary S' at ert' d wel ontraclor 1 Date
By signing this form,l hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02G.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature of the oJ'this record has been provided to the well owner.
repair under 921 remarks section or on the back of this farm.
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: 355 (fl•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferem(example-3 a 100'and 2 rr 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
fi Static water level below top of casing: 80 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfnater level is above casing,use"+"
6.25 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
rotary
12.Well construction method: 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
i
13b.Disinfection type: HTH Amount: 12 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018