GW1--05856_Well Construction - GW1_20230912

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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
100 ft• 705 ft.
4436-A ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased wells)OR LiNER>.(Kap licable)
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 44 ft• 6.25 : i"' 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.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.
'❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. •
❑industrial/Commercial CJResidential Water Supply(shared) 18.GROUT'.._ 1.
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL i 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. ,
❑Geothennal(Closed Loop) ❑Tracer ,20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft.
�4.Date Well(s)Completed: 08/15/2023 Well ID# ft. ft. :
5a.Well Location: ft. ft. l-ti::: ' ' + ...
' Watershed Properties/Mike Drinkwater ft. ft. i ' t �.�L..„
Facility/Owner Name Facility ID#(if applicable) ft. ft. SE P 1 2 2023
Round Top, DoubleTree Lane, Almond, NC 28702 ft. ft. Itld,nr r-,a f.7 1 ,'--• - •• V'f1�1
Physical Address,City,and Zip ft. ft. a va4r 0.71
Swain21.REMARKS.
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
35 degrees 22' 6" N 83 degrees 36'4" W � , ,
/<�-� � 8/15/2023
6.Is(are)the well(s): EPermanent or ❑Temporary Signature of Certified We�.ontractor Date
By signing this form,I hereby cert ifi,that the Well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or I'JNo ISA NCAC 02C.0100 or 15A NCAC 02Ct0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well 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 firm.
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-1 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 if different(example-3@a 200'and 2@l00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1�� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" l 1
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-lode 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 ove 1100,000 GPD: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: 27 oz
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018