GW1-2023-02228_Well Construction - GW1_20230307

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde aa.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3 fr. 180 fr.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 22 ft- 6.25 SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits 0.e.UIC,County,Slate,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. fr. in.
Water Supply Well: 17.SCREEN
PPY FRONT TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT
❑Irrigation ❑Wells>100,000 GPD FROM 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 fr. 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 ft. ft.To DESCRIPTION(color,hardness,soi0rock type, "n sire,etc.)
4.Date Well(s)Completed: 02/10/2023 Well ID# ft. ft
5a.Well Location: ft. ft
Tommy Woodard ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft `..` -• .q-' 'ti
2821 Watia Rd, Bryson City, NC 28713 ft. ft.
Physical Address,City,and Zip ft. ft.
Swain 2L REMARKS
County Parcel Identification No.(PIN) r,
'•°'}(" �,'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 degrees 21' 22" N 83 degrees 34' 42" W Ali 2/10/2023
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified well onuactor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NC:AC 02C.0100 or 15A NC:AC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under>21 remarks.section or on the back ol7his Jorm.
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 180 (ft.)
For multiple wells list all depths ifdifferent(example-3@a 200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following:
' 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: 3 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/fwater level is above caring,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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) 60 Method oftest: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 9 Oz
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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