GW1-2022-07038_Well Construction - GW1_20220727

WELL CONSTRUCTION RECORD(GW-1) 71e_ma1Ue0nly:
1.Well Contractor Information: _
Rick Crane 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. I ft.
3073_A ft. I ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Crane Bros. Well Drilling FROM TO DIAMETER THICKb'FSS MATERIAL
0 ft- 78 ft- 6.25 1- SDR 21 PVC
Company Name 16.INNER CASING OR TUBING(Feather a]closed-loop)
2.Well Construction Permit#:201 5-321 1-9-1 1 790 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) fL ft. is
3.Well Use(check well use): ft. ft.
Water Supply Well: FROM SCREENTO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) [nResidential Water Supply(single) R, ft. in.
❑Indusuial/Commercial ❑Residential Water Supply(shared) 19.GROUT
❑hTi lion ❑Wells>100,000 GPD FROM I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well. 0 it. 20 ft- benonite pumped
❑Monitoring ❑Recovery ft. fa
Injection Well: ft it.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK tir applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fa
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
FROM TO DESCRIPTION color,hardness,wilfrock e n size etc.
❑Geothermal(Heating/CoolingReturn) ❑Other explain under#21 Remarks) 0 it. 78 ft. Clay
4.Date Well(s)Completed:05-24-2022 Well ID# 78 it- 405 ft- granite
5a.Well Location: ft. ft.
Jimmy Hodgins n' n•
Facility/Owner Name Facility ID#(if applicable) ft. ft. 'r� •F
Dills Cove Road ft. ti}�
Physical Address,City,and Zip ft. H L 2 / 2022
Jackson 7632-83-6456 21.REMARKS
County Parcel Identification No.(PIN) pp .:fir b ti1�!dti:
f'r�•i$'4:Ji�'t 'i Ji' t✓1ir.�:rC_.Fc?�;:?ij lj\i I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. a illcation:
N35 20.453 N wo83 19.978 7/25/2022
6.Is(are)the well(s): 19Permonent or ❑Temporary Signs ure of Certified well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: []Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 02C.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 under#21 remarkv 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:405 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For inuinple wells list all depths ifdierent(example.3@200'and 2@100)
10. 20
m
24a. For All Wells: Original form to Division of Water Resources (DWR),
ff Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ij>+nter 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 Su 1 and O eo-Loo Geothcrtnal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environments health department of a county where instate
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 10 Method of test:a i r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Stenlene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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