GW1-2023-01601_Well Construction - GW1_20230214

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft. 400 ft. I;
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 ft• 25 ft.
6.25 i! i"' SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
Z.WCII CODStrnetl0n Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable bell construction permits(i.e.111C,County,State,variance,etc.) ft. ft. ij i"•
3.Well Use(check well use): ft. ft. in.
17.SCREEN li
Water Supply Well: FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. 01,
❑Geothermal(Heating/Cooling Supply) [IResidential Water Supply(single) ft. ft. in.'!
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❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 7ii
❑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.SAPiD/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 attachadditional sheets ifnecessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soilhnck a in sis,etc.)
4.Date Well(s)Completed: 01/03/2023 Well ID# ft. ft.
ft. ft. ' 2023
5a.Well Location:
Tyler Cook a ft. ft. ;; yy
jn,Ll1 ?r.',b ar i a
ft.'
Facility/Owner Name Facility ID#(if applicable)
- ft. ft.
Cullisia Rd;Bryson-City; NC-�28713-
- - ft. ft... :
Physical'Address,City;and Zip ,
Swain21.REMARKS
If
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: a
35 degrees 20' 39" N 83 degrees 27' 7" W li � 1/3/2023
6.is(are)the well(s)• OPermanent or ❑Temporary Signature
/oflCertified Well C Tractor Date
By signing this form,I hereby certify ihai`the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under P21 remarks section or on the back'ofthis;/brm. -
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 400 (R•) Submit this GW-1 within 30 days iof well completion per the following:
For multiple wells list all depths ifdii ferent(example-3 a@200'and 2 r@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 30 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:'6.25 (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 producing Itover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,'NC 27699-1011
13a.Yield(gpm) 'S Method of test: air f - --
13b.Disinfection type: HTH Amount: 15 OZ
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018