GW1-2023-02661_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
FROM TO DESCRIPTION.
Well Contractor Name
100 ft- 205 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- 46 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 well construction permits(%.e.C11C,County,State,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fr. in
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑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. 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. ft.
❑Geothemtal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,ha+dness,soillrock e, rain sim,etc.)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
4.Date Well(s)Completed: 03/29/2023 Well ID# ft. fr.
Sa.Well Location: ft. ft.
Whitney Gunter ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. g L LJ
Grassy Branch, Bryson City, NC 28713 ft. ft.
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 fatilong is sufficient) 22.Certification:
35 degrees 25' 10" N 83 degrees 30'43" W &ate el� 3/29/2023
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of CertifiedWel'.ontractor Date
By signing this form,f hereby certify that the well(s)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NC:AC 02C.0200 Well Construction Standards mrd that a copy
ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under=11 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 I 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: 205 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3 rt 200'and 2@1001
100 24a. For All Wells: Original form to Division of Water Resources (DWR),
fn Static water level below top of casing: (ft.)
Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwaterlerel is above casing,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-Lo'op 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) 15 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 6 oZ
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018