GW1-2023-02225_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
160 ft. 405 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. 68 ft. 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C 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.
❑Geothenmal(Heating/Cooling Supply) nResidential 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&AMOUNT
rNon-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 a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater 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,soilhnck type min sire,etc.)
ft. ft.
4.Date Well(s)Completed: 02/21/2023 Well ID# ft. ft.
5a.Well Location: ft. ft.
Watia Creek Contracting/Mark Johnson ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ;
Luther BinghamBingham Rd, Bryson City, NC 28713 ft. ft.
r
Physical Address,City,and Zip ft. ft. MAR o 4 L
Swain 21.REMARKS
County Parcel Identification No.(PiN) + "'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22.Certification:
35 degrees 18'45" N 83 degrees 35'46" W 111*" 2/21/2023
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified 11 Contractor Date
By signing this form,I hereby certify that the well(s)iras(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NC:AC.'02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a copy
IJ'this is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well corner.
repair under=21 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 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: 405 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3 a 00'and 2 rJ100')
160 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/fwater level is above casing,use "
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground hljection 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) 5 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 12 OZ
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018