GW1-2022-08785_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
40 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. 655 ft• 16.25 1 in SDR21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernries(i.e.1 IIC,County,Stale, 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. l
❑Geothermal(Heating/Cooling Supply) (')Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
❑irrl anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fl. 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. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach addifion5l sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: 08/16/2022 Well ID# ft. ft.
5a.Well Location: ft. ft.
Mark Crisp ft. ft. . s � { T r r .
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. _
1628 Ryefield Rd, Robbinsville, NC 28771 ft. ft- • -
Physical Address,City,and Zip ft. ft. 1flivi i;a .1 r'+f^''.?Xs oS:'f3 UnA
Graham 21.REMARKS udflu
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 22'42" N 83 degrees 49' 14" W ��" 1/ 8/16/2022
6.Is(are)the well(s): In Permanent or ❑Temporary signature of Certifie ell Contractor Date
by signing this form,I hereby cerlify that the well(s)was(were)constructed in accordance will?
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,fill out known sre//construction inf.,nnalion and explain the nature of the oflhis record has been provided to the well owner.
repair under#21 remarks section or on the back of7his 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.)
For multiple wells fist all depths if'd�erent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
40 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
/flwater 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) 15 Method of test: air
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 6 OZ
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Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018