GW1-2022-06702_Well Construction - GW1_20220712

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KalebT. Hyde 14.WATER ZONES 6
Well Contractor Name FROM TO DESCRIPTION
100 ft. 305 ft.
4436-A ft. ft. 1
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• 118 ft. 6.25 1" SDR21 PVC
Company Name 16.INNER CASING OR TUBING cothermal closed-loo
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
Li.sl all applicable trell construction pennils ri.e.U/C,County,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.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT . . .. _ 1 ',
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 ft. bentonite'
❑Monitoring ❑Recovery 17 fi- 20 ft. bentonite
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _-19.SAND/GRAVEL-PAC-K(if a licable
❑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
FROM TO DESCRIPTION(color,hardness,soillrock e, ruin sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 06/21/2022 Well ID# ft. ft.
ft. ft
5a.Well Location:
Ronald Thornton ft. ft.
ft.
Facility/Owner Name Facility ID#(if applicable) ft. •
715 Houston Farm, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip
ft. ft.
Swain 21.REMARKS 1
County Parcel Identification No.(PIN) ° i `i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: 7q
35 degrees 19' 7" N 83 degrees 27' 27" v A bw %, a1/2 0 2 2
Signature of Certified ell Conti-actor I pf� >lz5 1G
6.Is(are)thewell(s): OPermanent or ❑Temporary Si 6 I �tiV, ZJI�,I�,j
By signing this form,I hereby certify that thehrell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!]No MA NCAC 02C.0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ire/l construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofdris 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-l-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.)
For multiple wells list all depths lfdtfferent(example-3 rt 200'and 2 rr 100') Submit this GW-1 within 30 days of well completion per the following:
100 24a. For All Wells: Original form to Division of Water Resources (DWR),
/f
f Static water level Below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
u�aterlerel 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-!Loon 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) 3 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 9 oZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-2018