GW1--02481_Well Construction - GW1_20240423

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES I I
FROM TO DESCRIPTION
Well Contractor Name 135 ft. 605 ft.
4436-A ft. ft. I
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. 36 ft. 6.25 I� 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.U/C,County,State,Variance,etc.) 0 ft. ft. I' in.
3.Well Use(check well use): ft. ft. I: 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.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
1
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it• 17 ft• bentonite
❑Monitoring -DRecovery 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 additionafsheels if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etr.)
ft. ft.
4.Date Well(s)Completed: 03/08/2024 Well ID# ft. ft.
5a.Well Location: ft. ft.
Mark Degrandchamp ft. ft. I P. _ .,
Facility/Owner Name Facility lO//(if applicable)
ft. ft. �'."' Lair sr'a f' .:
192 Lake View Trail, Fontana Lake Estates,Bryson City,NC 28713 ft. ft. iAPR 2 r 2024
Physical Address,City,and Zip ft. ft.
Swain • 21.REMARKS ifi.v: t:. ' ./,.::::1..; ,y
Ld'i r•t.,.; Lk..i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35 degrees 23' 36" N 83 degrees 34' 18" W / a12.,6 r 1/ 3/8/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified 1 Contractor I Date
By signing this form,I hereby certt&that the wells)was(here)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,fill 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-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: 605 (ft.) Submit this GW-1 within 30 days of;well completion per the following:
For multiple wells list all depths if different(example-3 tr 200'and 2 rr 100)
135 24a. For All Wells: Original formj'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 I
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27 i 99-1636
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
I.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over��100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,Ne 27699-1611
13a.Yield(gpm) 4 Method of test: air
13b.Disinfection type: HTH Amount: 21 oz
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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