GW1--05020_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES. ,:-
Well Contractor Name FROM TO DESCRIPTION
4436-A 30 ft. 305 ft. ,
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• 80 ft• 6.25 in' 188 Steel
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(t.e.UIC,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. ft. in.
❑Geothermal(Heating/Cooling Supply) I lResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS: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)
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: 7/7/2023 Well ID# ft. ft.
5a.Well Location: ft. ft. {"-- ..7"/-% I
CTM Rentals ft. ft.
4 cz r.w' "s"
Facility/Owner Name - - - Facility ID#(if applicable) ft. ft. 'AUG
Robinson Gap Rd, Bryson City, NC 28713 ft. ft. -7 2023
Physical Address,City,and Zip ft. ff. In1�i; ,� 7 fi: '.� I I^
Swain •
21.REMARKS : : . . .--tl V,'=iOl " '
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 24' 52" N 83 degrees 28'43" W / . Yy 7/7/2023
6.Is(are)the well(s): in Permanent or ❑Temporary Signature of Certified Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infarmation and explain the nature of the of this record has been provided to the well owner.
repair under#2/remarks section or on the back of 1/sic 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 rD 00'and 2 a/00')
30 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
If water level is above casing,use"4-"
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
il.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 GPO:Copy to DWR,CCPCUA
1 air
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 12 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources , Revised 6-6-2018