GW1--04114_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14,WATER ZONES
FROM TO , DESCRIPTION
Well Contractor Name
20 ft 205 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 DIAMETER THICKNESS MATERIAL
0 ft' 79 ft 6.25 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.CAC County,State,Variance,etc.) 0 ft ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAI11I1'ER SLOT SIZE , THICKNESS \I ATERIA I.
CI 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
❑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. rt.
❑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
DExperimental 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 sin,etr.)
ft ft.
4.Date Well(s)Completed: 06/14/2024 Well ID# ft ft.
ft. ft.
5a.Well Location:
Benny Orr ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ,r``#i . 4 I
ft. ft 2 `
Physical Address,City,and Zip ft. ft. J U L 1 2024
Graham 21.REMARKS
County Parcel Identification No.(PIN) CohC-4 SCI1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r-
(if well field,one Iat/long is sufficient) 22.Certification:
35 degrees 22' 10" N 83 degrees 49' 19" w /<CL1.2 6/14/2024
6.Is(are)the well(s): in Permanent or ❑Temporary Signature of Certiee ell Convector Date
By signing this form,/hereby certify that the well(s)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,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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.) 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 2@I00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 20 (k) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use" "
6.2524b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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) 40 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: I ITl-I k,Hount: 9 oz
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018