GW1-2022-08786_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES i
Well Contractor Name FROM TO I DESCRIPTION
40 ft. 230 ft.
4436-A
ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for TEMAcased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. 43 ft• 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//construction permits(i.e. IX',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) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr• 17 fr• 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 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)
FROM TO DESCRIPTION(color,hardness,soillivek e, rain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well(s)Completed: 08/11/22 well ID# ft. ft.
5a.Well Location: ft. ft. r.,t_.„ �
Todd and Melissa McKeehan ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. HP 0 Q 0
9 `1
22
1051 Ryefield Rd, Robbinsville, NC 28771 ft. ft.
ft. ft.
Physical Address,City,and Zip r sp t
21.REMARKS
Graham
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 22' 38" N 83 degrees 49' 51 W li�� 1/ 8/11/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertifiedOVell Contractor Date
By signing this form,1 hereby certj�that the we//(s)was(mere)constructed in accordance wilt
7.Is this a repair to an existing well: ❑Yes or IINII 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1J'1his is a repair,fill out known well construction information and explain the nature oJ'rhe oJ7his record has been provided to the well owner.
repair under»21 remarks section or on the back oJ'lhis Jorm.
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: a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 230 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi/Jerent(example-3 r@r 200'and 2@I00')
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
//lraterlevel is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 9 OZ
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Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018