GW1-2022-10800_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.:WATERZONES I I
FROM TO DESCRIPTION
Well Contractor Name 200 It 805 ft.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING.for multi-cased iweBs OR LINER if a licable
Graham Well Drilling LLC FROM To DIAMETER THICKNESS MATERIAL
U ft. 179 ft- 6.25 i" SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(11.e.UIC,County,State.Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: U
pp y FROM TO DIAMETER I., SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.l I
❑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 a licable
❑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,soillrock e,grin sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 11/10/22 Well ID# ft. ft.
ft. ft.
5a.Well Location:
ft. ft. ' i_ e v�p ,
Allison Porter/Schumacher Homes of NC --4. '_ ` s V G-,,,,11~,_:
Facility/Owner Name Facility 1D#(if applicable)
ft. ft. � e-� .w _.
LULL
Fontana Lake Estates, Red Oak Ridge, Bryson City, NC 28713 fr. a. DE
t✓l;�
Physical Address,City,and Zip ft. ft. .ter^Y.'V V,t�� I •t
Swain 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
35 degrees 23' 33" N 83 degrees 34' 9" W 11/10/2022
I I
6.Is(are)the well(s): [nPermanent or ❑Temporary Signature of Certified el ntractor I I Date
By signing this form,I hereby certify that[he well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,filLout known well consiruction informalion and explain the nature of the of this record has been provided to the well owner.
repair under*1 remarks section or on the back of this 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-I 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: 805 11
(ft.) 1
For multiple wells list all depths ifili ferent(example-3 a 00'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
200 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 14 ,Raleigh,NC 27699-1617
lfwarerlerel is abort casing,use"+"
I I.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to'DWit,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(.-Pm) 1 Method of test: a
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 27 oZ
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources. Revised 6-6-2018