GW1--04739_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES
f FROM TO DESCRIPTION
Well Contractor Name
100 ft• 305 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• 114 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.(4C,County,State,Variance,etc.) 0 ft. ft. in.
3.Well Use(check well use): ft. ft. irk.
17.SCREEN
Water SupplyWell:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in-
❑Geothermal(Heating/Cooling Supply) lResidential 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)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) FROM TO DESCRIPTION(color-.hardness,soil/rock type,grain sin,etc.)
ft. ft.
4.Date Well(s)Completed: 07/16/2024 Well ID# ft. ft.
ft. ft.
5a.Well Location:
Elmo DeHart ft. ft.
Facility/Owner\.sne I u.ilu> ID#(if applicable) ft. ft. ,.,.4. y" ; i '
Double Springs, Almond, NC 28702 ft. ft. AUG 1 2 2024
Physical Address,City,and Zip ft. ft.
Graham 21.REMARKS 7•raint;"'.K1',itlt
IG{:r:n.4,.r.l
County Parcel Identification No.(PIN) D h'Cr�t n9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certification:
35 degrees 21' 2" N 83 degrees 40' 17" W AI 7 7/16/2024
6.Is(are)the well(s): l Permanent or ❑Temporary Signature of Certified contractor 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 l No 15A NCAC 02C.0100 or 15A NCA('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-2/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: 305 (ft.)
For multiple wells list all depths i/d Brent(exonrp/e-3@200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
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
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) 4 Method of test: a I r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: g OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018