GW1-2021-00095_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name It. ft.
FROM TO DESCRIPTION
4436-A aoo soy
ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a livable
Graham Well Drilling LLC FROM TO DIAMETER` THICKNESS MATERIAL
0 ft. 69 ft- 6.25 1n SDR21 PVC
Company Name
0385 FROM TO DIAMETER THICKNESS 16.INNER CASING OR TUBING eot hernial CI
2.Well Construction Permit#: THICKNESs MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc) 0 ft. ft. 1 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) L9Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM I 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 ❑Stonnwater 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 ft. TO DESCRIPTION(color,hardness,soil/mck a rain size,etc.)
ft.
4.Date Well(s)Completed: 10/12/2021 sell ID# ft. ft.
5a.Well Location: ft. ft. ff
Bob Lemieux f`' f`'
ATf Facility/Owner Name Facility ID#(ifapplicable) ft. ft. f
Lot#22 Fox Run Ridge, Bryson City, NC 28713
Physical Address,City,and Zip
Swain 21.REMARKS "' 9r++.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
35 degrees24' 8 " N 83 degrees 27' 52" W G.
10/12/2021
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby certify that the:u-ells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0I00 or I5A 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 of the of this record has been provided to the well owner.
repair under Ell remarks section or on the back o/7his form.
23.Site diagram or additional well details:
S.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-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: 805 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dtffereni(example-3@200'and 2@l00')
400 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
Ifivater level is above casing,use
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
rotary
Program, 1636 MSC,Raleigh,NC 27699,-1636
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) '25 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 18 oZ
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018