GW1--02484_Well Construction - GW1_20240423

1
, I
I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES I I .
Well Contractor Name FROM TO DESCRIPTION
100 it 205 'ft. l I
4436-A '
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased ivells)OR LINER(if ap licable)
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 53 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. 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) inesidential Water Supply(single) ft• - ft. ' in.I
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT U
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 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 additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soi0rock type,grain size,etc.)
ft. fL
4.Date Well(s)Completed: 03/28/2024 Well ID# ft. ft. _ _ _ _
Sa.Well Location: ft. ft. '�;, c. 4i.~.;: 1/ ?_.
Watia Creek Contracting ft. - ft. AIR 2r 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Black Forest/Trillium Branch Rd, Bryson City, NC 28713 ft. ft. tr:t.Ta:_,g;r .,--." ,z
•
Physical Address,City,and Zip I ft. ft. �f'.'V C '-t t
Swain 121.REMARKS
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 25' 3" N 83 degrees 30' 17" W K 3/28/2024
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified el,eontractor f Date
By signing this form,I hereby cert(that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA 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 d explain_the nature of the_ of this record has been provided to the well owner. -_ _
repair under tt21 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.) Submit this GW-1 within 30 days'ofwell completion per the following:
For multiple wells list all depths if different(example-3@a 200'and 2@100')
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
lfwater level is above casing,use"+"
11.Borehole diameter I
6.25 (in•) 24b.For Injection Wells:Copy tl DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary 24c.For Water Supply and Openl-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
13a.Yield(gpm) 30 Method of test: air
Permit Program,1611 MSC,Raleigh,!NC 27699-1611
13b.Disinfection type: HTH Amount: 6 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I