GW1--02411_Well Construction - GW1_20240422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information: I
Kaleb T. Hyde 14.WATER ZONES. l I
Well Contractor Name FROM TO DESCRIPTION
100 ft. 505 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 ft. 127 ft. 6.25 i in' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2023-25839-9-13303 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER• SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.j, I
❑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
❑Monitoring _ ❑Recovery - 17 ft. 20 -ft.- bentonite
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicablel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type grain size.etc.)
ft. ft.
4.Date Well(s)Completed: 03/21/24 Well ID# ft• ft.
ft. ft. '
5a.Well Location:
Dennis Crisp ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. t .`4.••'4. .T. s +.-•
437 Trickle Branch Rd/Thomas Valley Rd.Whittier, NC 28789 ft. ft. APR 2 2 2GZ4
Physical Address,City,and Zip ft. ft.
�• rrA
Jackson 7603-27-5134 21.REMARKS sj:c.:;: :'_'
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 25' 19" N 83 degrees 21' 25" W / .2_,, 5J/ 3/a1 124
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well tractor I 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 ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a 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 k21 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 I 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: 505 (ft.)
For multiple wells list all depths ifd�erent(example-3 a 00'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
100 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"+" I
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: 1
24d.For Water Wells producing o ier 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 3 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount: 18 oz
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Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6-6-2018