GW1-2021-04626_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: p 9
Jeff Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Nameq
2050-A M1M1 nY L�� 300 ft- 805 ft.
Qv'11� ry 1 1 ft. ft.
15.NC Well Contractor Certification Number �tSSlrtfJ V��
Graham Well DrillingLLC )Cti^i�l`3'�t�71 Jg tA� FROMUTER CASING form D AMETER ells OR ICKNESSfa hMATERAL
n �� ft. 83 ft- 6.25 in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.Slate,Marione,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) CJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑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: ft. 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
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 under#21 Remarks) FROM To DESCRIPTION(color,hardness,saiVrock e, rain size,etc.)
ft. ft.
4.Date Well 04/12/21 s)Completed: Well ID# ft. ft.
ft. ft.
5a.Well Location:
Al Conner/A C Capital ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Alarka Highlands Lot#39, 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 ladlong is sufficient) 22.Certification:
35 degrees 21' 45" N 83 degrees 22' 57" w (10 � 4/12/2021
6.[s(are)the well(s): CJPermanent or ❑Temporary Si ay
e Cen'' d eu ontractor Date
y signing Ihts form,l hereby certify that the wel1(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (INo I.iA 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 fire nature of the of this record has been provided to the well owner.
repair under#21 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 805 (ft.)
For multiple wells list all depths iftli fereni(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
300 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
If crater level is above casing,use-
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy toI DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1 63 6
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) 2 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
I
13b.Disinfection type: HTH Amount: 24 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources`. Revised 6-6-2018