GW1--06068_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'
Well Contractor Name FROM fi• 255 1t DESCRIPTION I ION
4436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased(wells)OR LINER(if Op licable)
Graham Well Drilling LLC FROM TO DIAMETER ; THICKNESS MATERIAL
0 ft. 84 ft• 6.25 j 1°- SDR21 PVC •
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. ft. 1 in.
3.Well Use(check well use): ft. ft. in•
17.SCREEN
Water Supply PP Y Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.I
❑Geothermal(Heating/Cooling Supply) Inesidential Water Supply(single) ft. ft. in.`
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT if:
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 17 ft• bentonite
DMonitoring . ❑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. 1
09/20/2024 ft. ft.
4.Date Well(s)Completed: Well ID# •---•,r
ft. ft. 1 ,-,..,-,...0.'LL ,,;9, 'Ls;
5a.Well Location:
Joe Robertson ft. ft. 1 O C T . 1 2024
'Facility/Owner Name , Facility ID#(if applicable) ft. ft.
Yellow Creek, Robbinsville, NC 28771 . .ft. ft If` `'�'' `l
•Physical Address,City,and°Zip • _ - ' • ft.` ft. L.i o;,c':V J ,
Graham . • 21.REMARKS_
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 24' 52" N 83 degrees 50'44" W /c�,� /d 1 9/20/2024
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of Certified Well
actor Date
By signing this form,I hereby(((,
cerlt&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or ISA 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 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 wellidetails:
•
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: 255 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifditferent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 25 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6.25 24b.For Injection Wells:Copy torrDWR,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'WATERSUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA,
1. _Yield 15 Method of test:'air
Permit Program,1611 MSC,Raleigh,NC 27699-1611 .
13b.Disinfection type: HTH Amount: 9 OZ I i
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018