GW1--01028_Well Construction - GW1_20240212

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
60 ft• 180 ft•
4436-A ft. ft. '
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 61 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.(/IC,County,State, Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. fL 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.
['Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type.vain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
01/08/2024 ft. ft.
4.Date Well(s)Completed: Well ID# w-} +r tt ,..
ft. ft. t aLL/ :lVE ,:
5a.Well Location: •
Zachary Shuler ft. ft. FEU 1 2 2o11
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Robinson Gap Rd, Bryson City, NC 28713 fL ft. tocrimrien;'!r4-.wooir.2 Jo,
Physical Address,City,and Lip ft. ft. GiVJG
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 23' 50" N 83 degrees 28" 59" W /a1¢46 1y/ 1/8/2024
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified I Contractor Date
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 itNo 15A N(A('02('.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this isa repair,Jill 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-I 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: 180 (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths idiifferent(example-3@200'and 2@I00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 (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 producing over 100,000 GPD:Copy to DWR,CCPCUA
18 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