GW1--06067_Well Construction - GW1_20241011

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name 15 ft. 130 ft. f
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4436-A et. 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. 73 ft. 6.25 , in. 188 Steel
Company Name 16.INNER CASING OR TUBING(gcotlermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C:,County,State,Variance.etc.) 0 ft. ft. ' in.
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3.Well Use(check well use): ft. ft. 1 in.
Water Supply Well: 17.SCREEN I, .
pp y FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) lResidential Water Supply(single) - ft. ft. in.I
❑Industrial/Commercial ❑Residential Water Supply(shared) 1 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,ere.)
ft. ft.
4.Date Well(s)Completed: 09/12/2024 ,yell ID# ft. ft.
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5a.Well Location: ft. fr.
Calvin Shuler ft. ft. _''1- :T.; I, 7_
Facility/Owner Name Facility ID#(if applicable)
ft. ft. ..�•A..:. +f d.m,?. ..
East Buffalo Circle, Robbinsville,NC 28771 ft. ft. OCT 1 '1 2024
Physical Address,City,and Zip ft. ft. F- w
Graham 21.REMARKS I. �., . ...• '>.
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 21' 59" N 83 degrees 50' 13" W Itia, ,
/� , 9/12/2024
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of CertifieContractor Date
By signing this form,I hereby cert((y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: :Wes or I`JNo I5A NCAC 02C.0100 or 15A NCAC 024.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature oldie of this record has been provided to the well owner.
repair under h21 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: 130 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@a,200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 15 (1.0 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!limiter level is above casing,use"+" I
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (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
60 air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
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13b.Disinfection type: HTH Amount: 6 oz
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018