GW1--06404_Well Construction - GW1_20231009

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f'
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES. . is i '
Well Contractor Name FROM TO DESCRIPTION
80 ft. 405 ft• I 1
4436-A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casediwells)OR LINER(if ap licable)..
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 87 ft. 6.25 I, 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.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) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I. 1
❑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 site,etc.)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 09/22/2023 Well ID# ft. ft
ft. ft. ''
. 5a.Well Location:
Jeffrey Etherton ft. ft. - .i- % r c,
Facility/Owner Name Facility IDt/(if applicable) ft. ft. ( .."� .'1•• i' tl' a- _•�°
1200 Eagles Roost, Alarka, Bryson City, NC 28713 _ ft. ft. 0 C T 0 9 2023
Physical Address,City,and Zip ft. ft.
Swain
"21.REMARKS .1 _1. Int: «.'^'i1 '"` ,J t-'1r•t
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 21'49" N 83 degrees 26' 2" W / ,, 7i/ 9/22/2023
6.Is are the wells: OPermanent or ❑Tem orary Signature of Certified Well C actor I Date
Is(are) O P
l
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I lNo 15A NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a copy
If 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 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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 80 (ft•) Information Processing Unit,1617 MSC Raleigh,NC 27699-1617
If water level is above casing,use"+" 1, '
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 2709-1636
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,161 l MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 10 Method of test: air 1
13b.Disinfection type: HTH Amount: 15 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018