GW1--06840_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kaleb T. Hyde 14.WATER ZONES 1 I
Well Contractor Name FROM TO DESCRIPTION
40 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. 84 ft. 6.25 ,in• 188 Steel
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(.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) ni Residential Water Supply(single) ft. ft. in: ,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT 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:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 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: 10/09/2024 Well ID# ft. ft.
ft. ft.
5a.Well Location:
John Crisp ft. ft. . ,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. • ' c a,•,'"%:•%V...., `.t, 1..,'...,
Cody Branch Rd, Robbinsville, NC 28771 ft. ft. NOV 1 o� 2024
ft. ft.
Physical Address,City,and Zip
Graham 21.REMARKS L,:',.,,:.... -. . y,;.`,J IA::
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' 58" N 83 degrees 41' 48" W /*612,4 �/ 10/9/2024
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified ' Contractor Date
l
By.signing this form,/hereby cent fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A 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 itJbrntation and explain the nature of the of this record has been provided to the well owner.
- repair under ft21 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land'surface: 305 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells.list all depths ifdifferen!(example-3@200'and 2@l00')
40 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
/f 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) 12 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 12 oz
•
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018