GW1-2023-01603_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: t
1.Well Contractor Information:
Kaleb T. Hyde .14.WATER ZONES I.
Well Contractor Name FROM TO DESCRIPTION
200 ft- 655 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 ft. 72 ft 6.25 ; in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,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.I.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in,1
❑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 - 0Recoyery 17 ft---20 ft- bentonit6
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation _._. .
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL I 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)
FROM TO DESCRIPTION(color,hardness,soi0rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft
i.
4.Date Well(s)Completed: 01/20/2023 well ID# fr. ft.
Sa.Well Location: ft. ft ` M L' - Ct'r' 4-L
Ron Miller f`. ft FEB tI ti2023
Facility/Owner Name Facility ID#(if applicable)
fr. ft. I,
The Falls, Bryson City, NC 28713 f` f` �" " �''r``
~v .+ •?sr
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lai/long is sufficient) 22.Certification:
35 degrees 23' 34" N 83 degrees 26' 24" W
A�� ,' 1/20/2023
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well nhactor I Date
By signing this form,I hereby certify that the irell(s)"'as(here)constructed in accordance with
7.Is this a repair to an existing well: []Yes or ItNo MA NC:AC 01C.0100 or i5A 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 of this record has been provided to the well ou ner.
repair under 921 remarks section or on the back-ofthis 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 655 (ft*) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3ca 200'and 2 a 100)
200 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"+" ; 1
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 vet 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 3 Method of test: air
Permit Program,1611 MSC,Raleigh',NC 27699-1611
13b.Disinfection type: HTH Amount: 21 oZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018