GW1-2023-02583_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14:wATERZONES
FROM TO DESCRIPTION
Well Contractor Name
70 ft- 255 ft.
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OWNER
if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. gg 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 hell construction permits(i.e.UIC,County,Slate,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. fr. in.
17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.,
[]Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑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: fr. fr.
❑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. fr.
❑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,soillrock type ain sim,etc.)
4.Date Well(s)Completed: 3/3/23 Well ID# ft. ft.
Sa.Well Location: ft. fr.
Bob Wehr ft. ft. - - - -
Facility/Owner Name Facility IDii(if applicable) ft. ft. �-
1861 Joyce Kilmer Rd, Robbinsville, NC 28771 , ft' ft. APR 1 �a
Physical Address,City,and Zip ft. ft.
Graham 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 22'46" N 83 degrees 53' 10" W 1<cr;" �/,,,,p� 3/3/2023
6.Is(are)the well(s): [nPermanent or ❑Temporary Signature of Certified WdYContractor Date
By signing this form,1 hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LINO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mtd 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 under: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: 255 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdii ferent(example-3 a 00'and 1@I00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: 70 (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water 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 I.
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) 10_. air .
Permit Program,16I I MSC,Raleigh,�NC 27699-1611
Method of test:
13b.Disinfection type: HTH Amount: 9 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 6-6-2018
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