GW1--02792_Well Construction - GW1_20240506

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Kaleb T. Hyde 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
4436-A 50 ft• 180 ft• 1 I
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casediwells)OR LINER(if ap licable)
Graham Well Drilling LLC FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ft' 94 ft• 6.25 '• in' SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable wed/construction permits(i.e.UIC County,State,Variance,etc.) 0 ft. ft. I in.
3.Well Use(check well use): ft. ft. 1 in.
17.SCREEN I
Water Supply Well:
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL •
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in.i ,
❑Industfial/Commercial 111Residential Water Supply(shared)
18.GROUT l i _... _.
El 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.
DAquifer 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,soil/rock type,grain sae,etc.)
ft. ft. 1
4.Date Well(s)Completed: 04/08/2024 Well ID# ft. ft. •
ft. ft.
5a.Well Location: r.....7, -,
Jacob Garland/tinny Sweet ft. ft. C.1,,,.....`-'i f T ; ;:
Facility/Owner Name Facility ID#(if applicable) ft. ft MAY 0 6 2024
Cody Branch, Robbinsville, NC 28771 ft. ft.
Physical Address,City,and Zip ft. ft lra i n.,- : ;; -- - , at
^DW`" ..ri
Graham 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: i
35 degrees 21' 30" N 83 degrees 42' 35" w /<aea, 4/8/2024
6.Is(are)the well(s): inPermanent or ❑Temporary Signature of Certified Al Contractor I + Date
By signing this form,/hereby cert&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
1/7hls is a repair,Jill out known well construction information and explain the nature of the oft/its record has been provided to the well owner.
repair under 62I 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: 180 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3@ a200'and 2 100')
50 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"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy t I 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 18 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-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018
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