GW1--04112_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
75 ft. 455 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 DIMETER THICKNESS MATERIAL
0 ft. 104 ft• 6.25 in* SDR21 PVC
Company Name
` 16.INNER CASING OR TIEING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DI.\METER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(//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) (Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑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 applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑ExperimentalTechnology ❑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 size,etc.)
ft. ft.
4.Date Well(s)Completed: 06/27/2024 Well ID# ft. ft.
5a.Well Location: ft. ft. :„
Scott Simpson ft. ft. �` -
•L.: �✓
Facility/Owner Name Facility IDN(if applicable) ft. ft. JUL 1 2 2024
Double Springs, Tobacco Branch, Almond, NC 28702 ft. ft.
Physical Address,City,and Zip ft. ft. '4`.,l w-r ram' i
Upea
Into:
Graham 21.REMARKS MCiiaC+a
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 22' 59" N 83 degrees 38' 3 " W Al.4 yi/-, 'actor 6/27/2024
6.Is(are)the well(s): (Permanent or ❑Temporary Signature of Certified ell Contr Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 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 of7his record has been provided to the well owner.
repair under ee21 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: 455 at.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 1@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 75 (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 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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
7 air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH M01111t: 18 oz
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018