GW1--03934_Well Construction - GW1_20230612

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
350 fir• 805 fir.
4436-A
fr. fit. ,
i
NC Well Contractor Certification Number 15.OUTER CASING for mull-cased,wells OR LINER if a livable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 fit• 22 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,roll construction perntils(i.e.UIC,County,Slate,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. fr. 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 ❑StormwaterDrainage ft. 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. To ft. DESCRIPTION(color,hardness,soillrock type,grain site,etc.)
4.Date Well(s)Completed: 05/24/2023 Well ID# ft. ft.
fir. fir. J s t.-.. '" .� - �••,,.
5a.Well Location: �t i_ •k'Y" ^^
Harvey Sutton ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. I 1 r
Fontana Trace, Lady Slipper, Almond, NC 28702 ft. ft. , _ "Jin
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:
(ifwell field one lat/long is sufficient) 22.Certification:
35 degrees 23' 3 " N 83 degrees 35' 20'i W !i_fC�I L 5/24/2023
6.Is(are)the well(s): InPermanent or ❑Temporary Signature oofCertifiie'd W zvcontractor Date
By signing this form,I hereby cerliJy that the well(s)u•as(were)constructed it,accordance u•tlh
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 If'ell Conslruclion Standards and/hat a copy
1f ihi.s is a repair,fill out known well construction itr/ornmtion 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 oJ'Ihis 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 805 Submit this GW-1 within 30 days of well completion per the following:
For nulliple wells lisl all depths ifdiJferent(example-3 n 200'and 2 t@i 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
ifi Static water level below top of casing: 350 (fit) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/'lrater level is above casing,acre"�"
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
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) 'S Method of test: all ,
13b.Disinfection type: HTH Amount: 21 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018