GW1-2023-01602_Well Construction - GW1_20230214

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 40 ft 305 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 M1fATER1AL
0 ft- 127 ft- 16.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits r.e.UIC,County,State,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fr. ft. im,
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in•;:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT i
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f1- 17 ft- bentonite
❑Monitoring ❑Recovery 1.7 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., ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return)
TO) ❑Other(explain under#21 Remarks) ft. fr. DESCRIP TION(color,hardness,soil/mck type@rain size,etc.)
4.Date Well(s)Completed: 1/10/2023 well ID# ft. ft. j .^{'t^,"T 1�,A n
ft. ft. o ., !l• a Gi ham. y
5a.Well Location:
Kyle Hill ft. ft. f FEQ i c• 2023
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Grassy Branch, Bryson City, NC 28713 f` f` " ,•. �:•
t,t n,=
ft. ft.
Physical Address,City,and Zip
21.REMARKS
Swain b
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hn/long is sufficient) 22.Certification:
35 degrees 25' 11" N 83 degrees 30' 45" W
/a� j 1/10/2023
6.Is(are)the well(s): tPermanent or ❑Temporary Signature of Certified w 27contractor I Dare
By signing this form,l hereby certjy that(he well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No I5A NC:AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out knoirn well construction information and explain the nature of the of this record has been provided to the trel/owner.
iepnir under=21 remarks section or of the back ofthis formes -
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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft•) Submit this GW-1 within 30 days,f well completion per the following:
For multiple wells list all depths ifdiJferent(example-3 a 00'and 2 tr 100)
24a. For All Wells: Original form,to Division of Water Resources (DR),
10.Static water level below top of casing: 40 W
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If Crater level is abore casing use"+" ! I
II.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 SUDDIV 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 i vl r 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 120Z
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018
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