GW1--01718_Well Construction - GW1_20240315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: 1.
Kaleb T. Hyde 14.WATER ZONES' 1 If
FROM TO DESCRIPTION
Well Contractor Name 15 fr• 305 ft- I
11
4436-A ft. ft. 1 11
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased stiells)OR LINER(if ap licable)
Graham Well Drilling LLC FROM TO DIAMETER I' THICKNESS MATERIAL
0 ft. 60 ft• 6.25 i"' 188 Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM , TO DIAMETER i _ THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State, Variance,etc.) 0 ft. ft. p iin'.
3.Well Use(check well use): ft. ft. iln.
Water Supply Well: 17.SCREEN I
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in. ;1
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .. 1 I I
❑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 fr• bentonite i •
Injection Well:
ft. ft. '
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM , TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary).
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,„min sire,etc.)
ft. ft.
4.Date Well(s)Completed: 02/20/2024 Well ID# ft. ft.
ft. ft. ,
5a.Well Location:
Kendall Smith ft. ft. _
Facility/Owner Name FacilityID# a applicable) ft. ft. a t%'•"% `; �r f„
ty (ifPP ) ���r L,L.L�, b? fl
Upper Sawyers Creek, Robbinsville, NC 28771 ft. ft. pp 7 I--
Physical Address,City,and Zip ft. ft. MAR I 5 2074
Graham 21.REMARKS I! I
1 tnfO;it E'il Pry..;sz.s4,r og unli
County • Parcel Identification No.(PIN) 3G
rot f ,•�G
UYY S^di 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;, 1
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 23' 26" N 83 degrees 43' 53 ' W /a12,6 1/ i , 2/20/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified ell Contractor Date
By signing this form,l hereby certt&that(he well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C./200 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 i caner.
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 wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.) Submit this GW-1 within 30 days;of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@l00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 15 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6.25 24b.For Injection Wells:Copy to IDWR,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-L'oop 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 I i ver 100,000 GPD:Copy to DWR,CCPCUA
6 air
Permit Program,1611 MSC,Raleigh NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 12 oz
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-2018
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