GW1--07910_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I'
1.Well Contractor Information: 1
Kaleb T. Hyde 14.WATER ZONES 1 I
Well Contractor Name FROM , TO DESCRIPTION
400 ft. 555 ft. I
4436-A ft. ft.
1i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased',wells)OR LINER(if ap licable)
Graham Well Drilling LLC FROM TO DIAMETER I THICKNESS MATERIAL
0 ft. 59 ft. 6.25 1. 4'. 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,Stale,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) 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 DGrdundwater 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,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) rt. ft. t
4.Date Well(s)Completed: 11/30/2023 Well ID# ft. ft.
•
5a.Well Location: fr. ft.
Ian Brooks ft' ft. , ,"
•
Facility/Owner Name Facility ID/ (ifapplicable) .. "•? t 0'
ft. ft. Q. ti. ' 't
DeHart Mill Rd; Bryson City, NC ,.28713 - ft. ft. EC to s 2023
Physical Address,City,and Zip ft. ft.
Swain 21.REMARKS. -1', ,:li:,.r1,.-+a<}il Cyr^�•r..„n
. L}vvE.J}iy
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 23'44" N 83 degrees 29' 32" W 11/30/2023
,""g_la.X o
6.Is(are)the well(s): nPermanent or ❑Temporary Sigtlatue of Certified et o�ntractor Date
By.signing this form,1 hereby certt&that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0/00 or I5A NCAC 01'.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under ii2l remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Ceoprobe/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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 555 (ft.) Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths iidii different(example-3@200'and 2@l00')
400 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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 producinglover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) '25 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH •Amount: 6,oz
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018