GW1-2023-00577_Well Construction - GW1_20230109

I.
WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information: a
Kaleb T. Hyde 14.WATER ZONES li
FROM TO DESCRIPTION
Well Contractor Name
80 ft- 255 fr. I
4436-A ft. %
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells 01 LINER,if a licable
Graham Well Drilling LLC FROM TO DIAMETER i THICKNESS MATERIAL
0 ft. 80 ft. 6.25 � !n SDR21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lisi all applicable hell construction permits(i.e.f/IC,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
❑irrigation ❑Wells>100,000 GPD FROM I 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 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 sheers if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock e, min size,etc.)
ft. ft.
4.Date Well(s)Completed: 12/22/22 Well ID# ft. ft.
Sa.Well Location: ft. ft.
Travis Moose ft. f`' IAN 0 G 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
357 DeHart Cove Road; Bryson City, NC 28713 ft. et.
ft. ft.
Physical Address,City,and Zip
Swain 21.REMARKS
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 24' 7" N 83 degrees 28' 42" W x6 12/22/2022
6.Is(are)the well(s): !JPermanent or ❑Temporary Signature of Certified Well ntractor I Date
By signing this form,I hereby certify iha[the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
IJ'this is a repair,fill out known well construction.lnlornmtimt and explain the nature of-the of ihis record hag been pror•ided to the well 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: 1 24.SUBMITTALINSTRUCTIONS
9.Total well depth below land surface: 255 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifeli ferent(example-3 a 00'and 2@100') i
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 it above casing,use'•+"
6.25 24b.For Injection Wells:Copy to I DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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 producinglover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 10 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 6 oZ
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource) I Revised 6-6-2018