GW1--07824_Well Construction - GW1_20231208

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: '
Kaleb T. Hyde 14.WATER ZONES )
FROM TO DESCRIPTION
Well Contractor Name
360 ft• 655 ft•
4436-A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedwells)OR LINER(if ap licable)
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 65 ft. 6.25 ' 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. .ft. in.
❑Geothermal(Heating/Cooling Supply) It Residential Water Supply(single) ft. ft. in.:
❑Industrial/Commercial ❑Residential Water Supply(shared) l' ' ..
I8.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. i
4.Date Well(s)Completed: 11/16/2023 Well ID# ft. ft.
5a.Well Location: ft. ft.
M. Wiggins Builders ft. ft. ^:,^ r� : .^; e,;.,,,::,•
Facility/Owner Name Facility ID#(if applicable) ft. ft. t ` 7 )
Rock Ledge Tsali Crossing North, Bryson City, NC 28713 ft. ft. DEC ii 8 2023
Physical Address,City,and Zip ft. ft. Iniwfr£. ;-{.n ',,., _a (iF
.
Swain
21.REMARKS . r i . :
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' 12" N 83 degrees 35' 27" W /a-42A i/...,, • 11/16/2023
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certifie, ell Contractor Date
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 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 construction info
construction,only 1 GW-1'is needed. Indicate TOTAL NUMBER of well's -(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: 655 (ft.) Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths ifd ferent(example-3 a 200'and 2@100') 1
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 360 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Borehole diameter: 6.25 (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
13a.Yield(gpm) 4.5 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 12 OZ i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018