GW1-2022-06920_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(CW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
60 ft. 205 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. 71 ft. 16.25 i" 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.UK',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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 "' 17 fc. bentonite
❑Monitoring ❑Recovery 17 ft. 20 ft. bentonite
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater 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,soillimck type,grain size,etc.)
4.Date Well(s)Completed: 05/18/2022 well ID# ft. ft.
5a.Well Location: ft. ft.
Chris Griggs Construction ft. ft. .e
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
Yellow Creek Rd, Robbinsville, NC 28771 ft. ft.
Physical Address,City,and Zip ft.
Graham 21.REMARKS
County Parcel Identification No.(PIN) U tz"M Et P�PI I Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 24'44" N 83 degrees 47' 37" W Aar ' 5/18/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ufCertified ell Contractor Date
By signing this form,1 hereby certify that the we/l(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or In No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lflhis is a repair,fill out known we/l construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under tit 1 remarks section or on the back of'ihis 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.)
For multiple wells list all depths ifdiffereni(example-3@200'and 1@100') Submit this GW-1 within 30 days of well completion per the following:
60 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
if 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,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
13a.Yield(gpm) 60 Method of test: air
Pen-nit Program, 1611 MSC,Raleigli,NC 27699-1611
13b.Disinfection type: HTH Amount: 6 oZ
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018
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