GW1-2023-02224_Well Construction - GW1_20230307

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES i.
Well Contractor Name FROM TO DESCRIPTION
200 ft- 455 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. 84 ft 6.25 in SDR21 PVC
Company Natne 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lisl all applicable irell construction pennils(i.e.(1/C,County,State,Irariance,etc.) 0 ft. ft.
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) PJResidential 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 S 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 sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness.soil/rock type.einin size,etc)
ft. ft.
4.Date Well(s)Completed: 02/22/2023 Well ID# ft. ft.
5a.Well Location: ft. ft.
Clifford Milner ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
628 Luther Bingham Rd, Bryson City, NC 28713 ft. ft. �',°.r
Physical Address,City,and Zip ft. ft. MAR
Swain 21.REMARKS
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:
35 degrees 18' 43" N 83 degrees 35' 50" W -" 2/22/2023
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified ell Contractor Date
By signing this Joan,I hereby cert�that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction inforn+ation and explain the nature of the of'this record has been provided to the ire/1 owner.
repair trader=21 ren:arks 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 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 455 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple ire/!s list all depths iJ'dperent(example-3 rr 100'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
ifiramr level is above casing,use "
11.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 producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 30 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type. HTH Amount: 12 oZ
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018