GW1-2022-06700_Well Construction - GW1_20220712

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
140 fr. 505 ft. i
4436-A !.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa Iicable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 130 ft• 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING cothermal closed-loo
2.Well Construction Permit th FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [']Residential Water Supply(single) ft. ft inl
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT G
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 ft- bentonite
❑Monitoring ❑Recovery 17 ft- 20 ft- bentonite
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stolmwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM I TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 06/01/2022 Well ID# ft. ft.
5a.Well Location: ft. ft.
Wiggins Builders rt. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
Rock Ledge, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS
County Parcel Identification No.(PIN) A+ Y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JUL 12(ifwell field,one hit/long is sufficient) 22.Certification: 2
35 degrees 21' 14" N 83 degrees 35' 11" W „ (,q y
/�CL� M!u r�� 7iilra 6/1/2022
Signature ofCertifie ell Co iiibd�t fi m,rim Ft-,,V4LJ i�G q
6.Is(are)thewell(s): C]Permanent or ❑Temporary I
By signing this form,1 hereby certify that the irell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards and that a copy
ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks,section or on die back oJ'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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Boz).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft.) Submit this GW-1 within 30 days of well completion per the following:
!or multiple hells list all depths ifdifferent(example-3@200'and 2@100')
140 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
[]'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
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) 4 Method of test: air ,
13b.Disinfection type: HTH Amount: 15 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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