GW1-2022-06411_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4436-A 120 fit- 305 ft.
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. gg ft- 16.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop
2.Well Construction Permit#: FROM TO DIAMETER I MATERIAL
List all applicable well consirtiction permils(i.e.UIC.County,Stale, Variance,etc.) 0 ft. ft. 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) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 17 ft- 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/rock type,grain size,etc.)
.r.
4.Date Well(s)Completed: 05/04/2022 Well ID# fr. ft. 1:7-
ft. ft.
5a.Well Location:
Chris Green ft. ft. �U
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft. �, j ^ •I
Impact Drive, Bryson City, NC 28713 ft. ft.
fr. ft. tt,� ti uti tt
Physical Address,City,and Zip :1'V'
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hn/long is sufficient) 22.Certification:
35 degrees 24'46" N 83 degrees 27' 56" w � 5/4/2022
N
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified II Contractor Date
By signing this form,l hereby cerliJ that the uvell(5)Bras(were)construcied in accordance with
7.Is this a repair to an existing well: ❑Yes or (I No ISA NCAC 02C.0/00 or 15A NC'AC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction infnrnmtion and explain the nature of the of this record has been provided to the well owner.
repair under=2l remarks section or on the back oJ7his 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tt'dii fereni(example-3 rCi 200'and 2 tt 100')
120 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
lJ water level is above casing,use
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,INC 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
13a.Yield(gpm) 9 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 9 OZ
i
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018