GW1--07321_Well Construction - GW1_20231113

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 300 ft. 805 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. 45 It 6.25 1 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.U/C,County,State,Variance,etc.) 0 ft. ft. j '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) nResidential 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 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. '
O 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,soiVrock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: 10/04/2023 Well ID# ft. ft.
5a.Well Location: ft. ft.
John Dodge ft. ft.
Facility/Owner Name FacilityID#(if applicable) ft. ft. 4--'
Eagles Roost/Cross View Drive, Bryson City,NC 28713 ft. ft. NOV
Physical Address,City,and Zip ft. ft. v 2��2�
Swain 21.REMARKS. i In' -•ca, -I
County Parcel Identification No.(PIN) C-U.'. "A`-;'"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 21' 53" N 83 degrees 26' 3" W /< YY •
10/4/2023
6.Is(are)the well(s): l!lPermanent or ❑Temporary Sibmature of Certifie ell Contractor Date
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l No 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#2/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-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:'1305 (ft.) Submit this GW-1 within 30 days o,f well completion per the following:
For multiple wells list all depths if different(example-3 a 00'and 2@100'
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 300 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!firmer level is above casing,use"+" i
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (inJ Program,1636 MSC,Raleigh,NC 21699-1636
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
13a.Yield(gpm) '5 Method of test: air
Permit Program,1611 MSC,Raleigh',NC 27699-1611
13b.Disinfection type: HTH Amount: 24 oz
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018