GW1--04346_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES ! I '
FROM TO DESCRIPTION
Well Contractor Name
100 fit• 705 ft.
4436-A ft. ft. --
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 109 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(i.e.Cl/(,County,State,variance,etc.) 0 ft. ft. its.
-
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. ft. in.
❑Geothermal(Heating/Cooling Supply) fnesidential 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 fit• 20 fit. 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)
❑ FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 06/13/2023 Well ID# ft. ft.
ft. ft.
5a.Well Location: r': •--4, -
Barry Wharton ft. ft. ! ', Le ., y�'�,b n
`'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Houston Farms Rd, Grizzly Ridge, Bryson City, NC 28713 ft. ft.
jU 0 7 2023
. Physical Address,City,and Zip ft. ft. Ifls�c ? Cn p�C,-. .Fi ;:u-�� Li,;„
21.REMARKS C,'•'+11t'S',-1t
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 19' 41" N 83 degrees 26' 48" W Xc .6 // I 6/13/2023
6.Is(are)the well(s): I�Permanent or ❑Temporary Signature of Certified ell Contractor Date
By signing this form,/herehy certt&that the well(s)was(weref constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or eiNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Obis is a repair,fill out known well construction information and explain the nature of the- gfthis record has been provided to the well owner.
repair under:21 remarks section or on the back of tins 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: t 24.SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: 705 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd(erent(example-3 cr 200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 100 (fitO Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b. For Injection Wells:Copy to DWR,. Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (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
3'S a I r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 27 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-20I8