GW1--02409_Well Construction - GW1_20240422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Kaleb T. Hyde 14.WATER ZONES II
FROM TO DESCRIPTION
Well Contractor Name -
40 ft. 160 ft.
4436-A ft. ft.
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 It 160 ft• 6.25 ' in. 188 Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2023-25252-9-13415 FROM TO DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) 0 ft. ft. i in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
❑Agricultural ❑Municipal/Public ft. ft. in.j,
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.!
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT I'
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. 17 ft. bentonite
❑Mon itoring , - - - ❑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 iseiessary)
❑Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM TO DESCRIPT•
ION(color,hardness,soil/rock typegmin size,eta)
ft. ft.
4.Date Well(s)Completed: 03/15/2024 Well ID# ft. ft.
ft. ft. 1...�= • •
5a.Well Location: I. _ •t . . ,a w., i 3.
Sherman Perry Freshour, Jr. ft. ft. RR [[,,
Facility/Owner Name Facility ID#(if applicable) ft. ft. H P n tts [U24
• 45Jean Hold Rd/Union Hill Rd, Sylva, NC 28779 ft. ft.
Physical Address,City,and Zip ft. ft. CM C1'•31 y;,
Jackson 764-15-1096 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 26'42" N 83 degrees 19'44 " W / ale-,6 y' ' 3/15/2024
6.Is(are)the well(s): CIPermanent or ❑Temporary Signature of Certifi6Vell Contractor j Date
By signing this form,I hereby certify that the tie/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known,cell construction information and explain.the nature of the of this record has been provided to the well owner_
repair tinder r'2l 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 160 (ft.)
For multiple wells list all depths if different(example-3 rt 00'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 40 (ft.) Information Processing.Unit,1617 M�C,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6.25 24b.For Injection Wells:Copy to DWR,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-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 o Ierl100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 6 OZ
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018