GW1-2022-07367_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KalebT. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
100 ft- 305 rr.
4436-A ft. ft.
r
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
ft. 550 ft. 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER ITHICKNESS MATERIAL
List all applicable hell construction permits(i.e.11/C.County,State, Variance,etc.) 0 ft. ft. j in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: I
FROM TO DIAMETERI SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM I TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 ft- bentonite
❑Monitoring ❑Recovery 17 ft- 20 ft- bentonite
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I 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 ft. To ft. DESCRIPTION(color,hardness,soll/mck type,grain size,etc.)
4.Date Well(s)Completed: 7/1/2022 Well ID# ft. ft. - 8
9
Sa.Well Location: ft. ft.
Jim Granger ft. ft. 2Q2-
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Pickett Trail, Bill Crisp Rd, Robbinsville, NC 28771
Urrd
Physical Address,City,and Zip ft. ft. `
Graham 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 23' 34" N 83 degrees 43' 36" W
' 6 7/1/2022
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified VI Contractor Date
By signing dris.fium,/hereby certify that the we//(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Slandards and that a copy
/fthis is a repair,Jill out known well construction u#brmation and explain the nature o/7lle ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back oJ'rhis Jonn.
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.)
For multiple sve//s list a//depths tJdiJferent(example-3 a 200'and 2 a@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),
Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
It water level it 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 I:over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 9 OZ
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018