GW1-2022-09957_Well Construction - GW1_20221104

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 $Q ft- 330 ft.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased veils OR LINER{if a 'limble
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. g5 ft• 6.25 i" SDR21 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 permits ri.e.111C County,State,Variance,etc.) Q 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) CJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT A
❑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 WeII: 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 additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. ft.To DESCRIPTION(color,hardness,soil/mck type,grain sim,etc.)
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4.Date Well(s)Completed: 10/03/2022 Well ID# ft. ft.
5a.Well Location: ft. fr.
Lujan Maria ft. ft. �.. >+ -a^a�'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2022
DeHart Cove Rd. Bryson City, NC 28713 ft. ft. -
Physical Address,City,and Zip ft. ft. jOit.iiliB;D1 t�f ?,yj;ZJ(.;rill
Swain 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lattlong is sufficient) 22.Certification:
35 degrees 24' 10" N 83 degrees 28'40" W !i �l j 10/3/2022
6.Is(are)the well(s): [']Permanent or ❑Temporary Signature
lofCertified Well ntractor Date
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By signing this form,I hereby certify that the irell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo I5A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
if this it a repair,fill out known well construction information and explain the nature of tile ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back of this,/brni.
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: 330 (ft*) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100')
10.Static water level below top of casing: 80 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ifivater level is above casing,use"+"
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6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
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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) 13 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 12 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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