GW1-2022-03909_Well Construction - GW1_20220412

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: F
KalebT. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
285 fr. 705 rr.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multAcased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 126 ft- 6.25 in SDR21 PVC
Company Name
0477 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.1.11C,County,State, Variance,etc.) 0 ft. ft. ! in.
3.Well Use(check well use): ft. fr• in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. 1.
❑Geothermal(Heating/Cooling Supply) IhResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 17 ft. bentonite
❑Monitoring ❑Recovery 17 ft. 20 ft. bentonite
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(ifapplicable
❑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)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 3/172/2 Well ID#
fr. fr. _
5a.Well Location:
Syl Turner rt. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. APR -2 7
Watia Rd, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS �mr-1Mi `''::'gJ�'
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 21' 42" N 83 degrees 34' 9" W a" 1/ 3/17/2022
6.Is(are)the well(s): CJPermanent or ❑Temporary Signahwe of Certified Contractor Date
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By signing[hiss form,1 hereby cerub,that the a ells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!nNo 15A NC'AC 02C.0100 or I5A NCAC 02C 0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information and explain the nature ofthe o./this record has been prorided to the well owner.
repair under'-'21 remarks section or on the back of this./brit
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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 705 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@a 200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DR),
10.Static water level below top of casing: 285 W
(ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caring,use"4."
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 depart rent 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) '75 Method of test: air
Permit Program, 1611 MSC,Raleigh`,NC 27699-161 1
13b.Disinfection type: HTH Amount: 18 oZ
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Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20 18