GW1-2021-02505_Well Construction - GW1_20211008

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde la.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft- 505 ft.
4436-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING far mulfi-cased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 126 ft 6.25 " 1188 Steel
Company Name 16.INNER CASING OR TUBING etithermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.1/1C,CounA,.,Stale. Variance,etc) 0 ft.
3.Well Use(check well use): fr. fr. in.
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Water Supply Well: 17.SCREEN I
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 17 ft.
❑Monitoring ❑Recovery 17 ft. 20 fr.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fr. fr.
❑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,soillrock type,grain size,etc.)
ft. fL
4.Date Well(s)Completed: 9/24/21 Well ID# ft. ft.
Sa.Well Location: tr. ft.
Patty Cable ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. OCT n
3101 Hwy 28, Almond, NC 28702 fr. fr. ��yf
Physical Address,City,and Zip ft. ft. n pro`,
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Graham 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
35 degrees 22'42" N 83 degrees 39' 54" W 9/24/2021
6.Is(are)the well(s): [nPermanent or ❑Temporary Signature of Certified WVContractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or In No 15A NCAC 02C.0100 or 15A NCAC 02C.b200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature o/'the al'this record has been prorided to the well owner.
repair under#21 remarks section or on the back oflhis 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 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft.)
multiple wells list a//depths ifdifferent(example-3 ct 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
For
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30 24a. For All Wells: Original formi to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
1f water level is above casing,use"<" I
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 over,100,000 GPD:Copy to DWR,CCPCUA
1 air Permit Program, 1611 MSC,Raleigh,�C 27699-1611
13a.Yield(gpm) Method of test: r
13b.Disinfection type: HTH Amount: 21 oZ
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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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