GW1-2022-06922_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
10 ft. 155 ft-
rt. rr.
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
p ft. 54 ft• 6.25 i" SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countyy,Slate, 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) I'Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑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 applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fr.
❑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,soiViock type,grain sim,etc.)
ft. ft.
4.Date Well(s)Completed: 05/24/2022 well ID# fr. ft.
5a.Well Location: ft. ft. lP"'
Rusty Williams ft. ft'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Yellow Creek Rd, Robbinsville, NC 28771 ft. ft.
Physical Address,City,and Zip ft. ft. t^s c,
Graham 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22.Certification:
35 degrees 25' 2" N 83 degrees 51' 32" W &aA,�- 5/24/2022
6.Is(are)the well(s): [nPermanent or ❑Temporary Signature of Certified W Contractor Date
By signing this form,I hereby cerlt&that the ire//(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
IJ'lhi.s is a repair,fill oul known ire//construction information and explain the nature of the oJ'this record has been provided to the well owner.
repair under 921 remarks section or on the back of lhis 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: 155 (ft.)
For multiple we//s list a//depdts ifdiifferent(example-3@200'and 25t100') Submit this GW-1 within 30 days of well completion per the following:
10 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
q'waler level is above casing,use"=" p
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells:Copy t DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27 699-1636
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) 40 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount: 6 oZ
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources f Revised 6-6-2018