GW1-2022-07037_Well Construction - GW1_20220727

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
' ft. fit.
3073 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR-LINBR if a Iienble
Crane Bros. Well Drilling FROM TO DL1afETER THICKNESS MATERIAL
0 ft. 127 ft- 6.25 In SDR 21 PVC
Company Name
2018-11084-9-7637 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable it-ell construction permits(l.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. it I in.
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) tt. ft. Ia
❑Industrial/Commercial ❑Residential Water Supply(shared) T8.GROUT
OIrrigaflon ❑Wells>100,000 GPD FROM I TO I MATERIAL EMPLACEMENT METIiOD&AMOUNT
Non-Water Supply Well: 0 fit 20 ft. benonite pumped
❑Monitoring ❑Recovery [t, ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑StormwaterDrainage ft. H.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Heating/Conlin Return) ❑Other explain under#21 Remarks FROM To I DESCRIPTION color,hardness,soluroch type,grain dw,etc
0 fit. 127 ft IClay
4.Date Well(s)Completed: 05-18-2022 Well ID# 127 fL 230 f" granite
So.Well Location: rt. ft.
Joseph Conforti ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ji Green's Creek ft. ft. 702�
Physical Address,City,and Zip ft. ft.
Jackson 7620-54-4120 21.REMARKS U 1-1% IJNi I
County Parcel Identification No.(PIN)
Si lti lr� i1
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cerd ation:
N35 20.069 N wo83 16.508 �� 7/25/2022
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCortified Well Contractor Date
By signing this form,I hereby cer*that the xvll(s)was(were)constructed in accordance trdth
7.Is this a repair to an existing well: ❑Yes or LINo 15A NCAC 01C.0100 or 13A NCAC 01C.0100 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 tinder#21 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:230 (ft•) Submit this GW-1 within 30 bays of well completion per the following:
For multiple wells list all depths ifdi ferent(example-3 a(200'and 2@100)
24a For All Lus: 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
IJwnter level is above casing,sere"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWI,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Su 1 end O en-Lon Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push,etc.) county environmental heal department of the county w ere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)30 Method of test:air Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type:Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I