GW1-2023-02665_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 J DESCRIPTION
Well Contractor Name
ft.
175 ft- 480
4436-A T .r. :: l'R �...
ft. ft.
NC Well Contractor Certification Number APR 1 12023 15.OUTER CASING for multi-cased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
:7 t1f is 0 ft. 44 ft. 6.25 in. SDR21 PVC
Company Name J
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable wel/construction permits(i.e.CIIC,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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IlResidential 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. 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)
❑Geothermal(Heating/Cooling Return)
TO) ❑Other(explain under#21 Remarks) ft. ft. DESCRIPTION(color,hardness,soil/rock type,ginin siw,etc.)
4.Date Well(s)Completed: 03/27/23 Well ID# ft. ft.
5a.Well Location: ft. ft.
Erika Wiggins ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
435 Shepherds Creek, 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 lat/long is sufficient) 22.Certification:
35 degrees 25'40 " N 83 degrees 25' 17" W 3/27/2023
6.Is(are)the well(s): OPermanent or ❑Temporary Signantre of Certified We ontractor Date
By signing this form,I hereby certify that the well(k)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 01C.0100 or 15A NC:AC 02C.0200 Well Construction Standards and that a copy
If-this is a repair,fill out known tveil 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-I 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: 480 (ft.)
For multiple wells list all depths if different(example-3(a 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
175 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifrrater level is above casing,use
I I.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
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 producin> over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 40 Method of test: air
Permit Program,161 1 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 15 oZ
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018