GW1--06405_Well Construction - GW1_20231009

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I i
1.Well Contractor Information:
Kaleb T. Hyde 14.'WATER ZONES S 'I
Well Contractor Name FROM , TO , DESCRIPTION
50 ft. 180 ft. ( !
4436-A
ft. ft. i
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. 72 ft 6.25 ; in• SDR21 PVC
Company Name
16.INNER CASING OR TUBING(pe sthermal 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER ; SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. '
Geothermal(Heating/Cooling Supply) Inesidential Water Supply(single) ft.l ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I '
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❑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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
ft. ft.
4.Date Well(s)Completed: 09/19/2023 Well ID# ft. ft. _ )
ft. ft. . ^. ,L • 'aa ii I.
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5a.Well Location: '�" 8" t
David Hughes ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. I
OCT 0 9 7073
170 Trent Field, Bryson City, NC 28713 ft. ` ft. ,1.;� ..... .�•' �'
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:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 24' 1" N 83 degrees 9' 0" w /c1� 1/ 9/19/2023
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well ontractor I Date
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By signing this form,I hereby certifr that theiwell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or in No 15A NCAC 02C.0100 or 15A 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.constructior.info.
constniction,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: 180 (ft.) i
For multiple wells list all depths rfdiljerenr(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
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24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 50 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I '
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
30 air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 6 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018