GW1-2022-03912_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
100 ft- 230 ft.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 108 ft 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(/I(',('aunty,State, Variance,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. I
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❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It' 17 l" bentonite
❑Monitoring El Recovery 17 ft- 20 ft- bentonite
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 ft. To ft. DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
4.Date Well(s)Completed: 03/22/2022 Well ID# ft. ft.
Sa.Well Location: ft. ft.
Fontana Lake Builders f`' ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. APR 1
Fontana Lake Estates,Appalachian Way, Bryson City, NC 28713 ft. ft. `
Physical Address,City,and Zip ft. `''�•`-X I iSlYsi
Swain 21.REMARKS "a s�'tr t?',,.r:'iI( d41`',li'I I'll
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 23' 32 " N 83 degrees 31' 59" W 1.'* .6 1/ 3/22/2022
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature ofCertifieedd�ell Contractor Date
By.signing this form,thereby cerlift that the well(.$)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or dNo 15A NCAC 02C.0100 or 15A NCAC 02(',.0200 Well Construction Standards and that a copy
If this is a repair,fit/out known well construction information and explain the 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 230 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if'different(example-3 c@t 200'and 2 a 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 100 (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lflvater level is above casing,use"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy tobWR,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 Iver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 40 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 6 oZ
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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