GW1-2021-00264_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 120 ft- 305 ft.
4436-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ells OR LINER ifa licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name p ft. 120 ft 6.25 I i" I SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C.,County,State, Variance,etc.) p ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 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 ❑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,soil/mck type, rain size,etc.)ft. ft.
4.Date Well(s)Completed: 1 1/8/21 Well ID#
5a.Well Location: ft. ft.
Carol Melanson ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Robinson Gap Rd, Lazy O' Farm, 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:
(ifwell field,one]at/long is sufficient) 22.Certification:
35 degrees 24' 48" N 83 degrees 28' 49" W 11/8/2021
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature ofCertif Well Contractor Date
By signing this.jorm,/hereby certify that the w-e1/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or OND 15A NCAC 02C.0100 or 15A NCAC 02C.6200 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 prorided to the well owner.
repair under k21 rentarl s section or on the back q(:ihi.s.%rm: - -
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.)
For multiple wells list a//depthsifdr(feretn(example-3 ct 200'and 2 n/00') Submit this GW-1 within 30 days of ell completion per the following:
lrafer level is above casing,use"+ 120 24a. For All Wells: Original form^to Division of Water Resources (DWR),
U Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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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 ov Ir 100,000 GPD:Copy to DWR,CC P e A
13a.Yield(gpm) 15 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 9 oZ
Fonn GW-) North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018