GW1-2022-06710_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
200 ft- 405 ft.
4436-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR 6iNER if a licable ..
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 57 ft- 6.25 • in SDR21 PVC
Company Name 16.INNER CASING OR TUBING -isothermal closed-loo.
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,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) MResidential Water Supply(single) ft. ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) .18,GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATER►ALI EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 17 fL bentonite
OMonitoring ❑Recovery 17 ft. 20 It- bentonite
.Injection Well: ft. ft.
-- - _-❑Aquifcr.Recharge_ ____ ❑GroundwaterRemediation_
19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity,Barrier FROM TO MATERIAL I 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 To DESCRIPTION(color,hardness,soil/i ock a rain siu,etc.)
fr. ft. �
4.Date Well(s)Completed: 06/30/2022 Well ID# ft. ft. I
5a.Well Location: ft. ft.
Robert Vincent ft. fr. ! t�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
161 Pickett Trail, Bill Crisp Road, Robbinsville, NC 28771 ft. ft.
Physical Address,City,and Zip ft. ft. t,
Graham 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 22' 31" N 83 degrees 41' 31" W 6/30/2022
6.Is(are)the well(s): nPermanent or ❑Temporary Signature ofCertified ell Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJ•this is a repair,Jill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 921 remarks.section or on the 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 bf wells "" (add'See Over'-in-Remarks'Box):YouSnav also attach additioiial'pages if necessary.
drilled: + 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@1001
200 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJ'water level is above casing,use"+" !
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy toi DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 2,7699-1636
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 ver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 12 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
i
13b.Disinfection type: HTH Amount: 9 Oz
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018
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