GW1--04113_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.N VIER ZONES
Well Contractor Name FROM ro DESCRIPTION
80 ft• 605 tt.
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. 70 ft• 6.25 in. SDR21 PVC
Company Namc
I s.I N N ER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM • TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK',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) nResidential 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.
❑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 size,etc.)
ft. ft.
4.Date Well(s)Completed: 06/07/2024 Well ID# ft. ft.
ft. ft.
Sa.Well Location:
Riley Anderson ft. ft. [-� _L.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. �! '.L •1 R i/E L)
Lower Tuskeegee, Robbinsville, NC 28771 ft.
ft. JUL 1 2 Z024
Physical Address,City,and Zip ft. ft.
Graham 21.REMARKS Irrd:./: .i^.•t ?-r•.r0A4-4 ijriT
County Parcel Identification No.(PIN) CPA Clt I1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 25' 0" N 83 degrees 41' 34" W /i .6 1/�•I„/` 6/7/2024
6.Is(are)the well(s): (!Permanent or ❑Temporary Signature of Certified Well pl/rie.
Date
By.signing this form,I hereby cert(that the sell(,)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or itNo 15A NCAC 02C.0100 or 15A N(A('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,: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 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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft.)
For multiple wells list all depths ifdii Brent(example-3@200'and 2@100) Submit this GW-I within 30 days of well completion per the following:
80 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 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
13a.Yield(gpm) •S Method of test: a I r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 24 OZ
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018