GW1-2023-00576_Well Construction - GW1_20230109

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES s
FROM TO DESCRIPTION
Well Contractor Name
125 ft. 430 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 f1. 80 ft. 6.25 1 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER 1 THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,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 fr. ft. io.,
❑Geothermal(Heating/Cooling Supply) [!)Residential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 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 fr. 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 fr. fr.To DESCRIP 1.TION(color,hardness,soillrock type rain size,etc.)
4.Date Well 12/20/22 ft. ft.
Completed: Well ID#
ft. ft.
5a.Well Location:
Jeff Ross ft. ft. JAN 0 9 2023
ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. � ���„�;,,� i 1.•t
Black Forest, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
.Swain 21.REMARKS I.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 22.Certification:
35 degrees 25' 23" N 83 degrees 30' 2" W ura" I1 12/20/2022
6.Is(are)the well(s): nPermanent or ❑Temporary Signature ofCertified We Contractor_ I Date
By signing this farm,I hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 15A NCAC 02C.0100 or 15A NC:AC 02C.0200 Well Construction Standards and that a copy
ifthis Is a repair,fill out l7701rn well construction information-and explain-the nature ofthe -ofthis record has been prmtded to the welt owner.
repair under 2l 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-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: 430 (ft') Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths ifdierent(example-3 a 00'and 2Ca 100')
125 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
Ifirater level is above casing,use"+"
I L Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
rotary
12.Well construction method: 24c.For Water Supply and Open!Ltiop 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) 6 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount: 15 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018