GW1--06817_Well Construction - GW1_20241114

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES i _
Well Contractor Name FROM TO DESCRIPTION
250 ft 605 ft
4436-A ft. ft.
. 1
CASING
NC Well Contractor Certification Number (for multi-cased*efts)OR LINER(if ap licable)_
Graham Well Drilling LLC FROM TO DIAMETER ' THICKNESS MATERIAL
0 ft. 59 ft. 6.25 i 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.U/C,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 DResidential Water Supply(shared) 18.GROUT
II I
❑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: --- -
rt. 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. 1
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional'sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) .
ft. ft.
4.Date Well(s)Completed: 10/22/24 Well ID# ft. ft.
5a.Well Location: ft. ft.
I
Jeff Marton ft. ft. ">
ft. ft. C .i t ... -_. s ` s:.^--,
Facility/Owner Name Facility ID#(if applicable) •�,a y, ,' b y' . .
Fontana Ridge Rd, Bryson City, NC 28713 ft. ft. NOV '�- �
Physical Address,City,and Zip ft. ft A CQZ4
Swain 21.REMARKS li i '-.- ^
• .
County Parcel Identification No.(PIN) ''..:- 'u f;*
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 degrees 25' 57" N 83 degrees 29' 52" W ae Yy
10/22/2024
6.Is(are)the well(s): 11Permanent or ❑Temporary Signature of Certifie. ell Contractor Date
By signing this form,I hereby cert(/that ilk wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or In No I5A NCAC 02C.0100 or I5A 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 well details:
8.For Geop'robe/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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft.)
For multiple wells list all depths if different(example-3@a 200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
I
250 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 departmentiof 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) 2.5 Method of test: air
Permit Program,1611 MSC,Raleigh,INC 27699-1611
13b.Disinfection type: HTH Amount: 15 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018