GW1-2023-02227_Well Construction - GW1_20230307

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 100 ft- 505 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 f1. 64 ft- 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irell 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ItResidential 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
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)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 02/07/2023 Well ID# ft. ft.
5a.Well Location: ft. ft.
- ,
Slick Rock Custom Homes ft' f`' l-�:- - f
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1495 The Falls East Alarka, Bryson City, NC 28713 ft. ft. R
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 lat/long is sufficient) 22.Certification:
35 degrees 23' 31" N 83 degrees 26' 7" W !iGo/l� 1// 2/7/2023
6.Is(are)the well(s): [nPermanent or ❑Temporary Signature f Certified YAI Contractor i Date
By signing this form,i hereby certify that the ire//(s)was 61'ere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IItNo 15A 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 of this record has been provided to the well owner.
repair tinder-21 remarks•section or on the back of this 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: 505 (ft•) Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths ifili ferent(example-9@200'and 2 tr 100')
100 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifsrater level is above casing,use"+"
6.25 24b.For Injection Wells:Copy to DWR,Underground,Injection Control(IUC)
11.Borehole diameter: (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 over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 4'5 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 18 oZ
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018