GW1-2023-00579_Well Construction - GW1_20230109

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
150 fr. 305 fr. I I
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulf'-casediwells OR LINER if a licable.
Graham Well Drilling LLC FROM TO DIAMETER THICIvVESS MATERIAL
0 ft. 35 ft. 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. fr. in
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in'
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in•f
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.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. 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).
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(cola,hardness,soiUrock e, rain size etc.)
fr. fr. I
I
4.Date Well(s)Completed: 12/13/22 Well ID# ft. fr.
ft. ft. I
5a.Well Location:
Mike Pinelli ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Long Br. Rd, Needmore, Bryson City, NC 28713 ft. ft. Q 2023
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS.
1414
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 18' 25" N 83 degrees 31'42" W 12/13/2022
6.ls(are)the well(s): IlPermanent or ❑Temporary Signature of Certified VI Contractor I Date
By signing this form,l hereby certify that the irell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C:.0100 or 15A NC:AC 02C.0200 Well Construction Standards and that a copy
t0his is a repair,fill out known wei/construction information and explain the nature of the _ of[his record has been provided to the well owner. _
repair under='21 remarks.section or on/lie 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 I 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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft') Submit this GW-1 within 30 dayJof well completion per the following:
For multiple wells list all depths ifdi•JJerent(example-3 a200'and 2«100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 150 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is abore casing,use I".. , I
I I.Borehole diameter: 6.25 (in,) 24b.For Injection 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingiover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 10 Method of test: air
Permit Program,1611 MSC,Raleigh,INC 27699-1 61 1
13b.Disinfection type: HTH Amount: 6 oZ
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
I Revised 6-6-2018