GW1-2022-07040_Well Construction - GW1_20220727

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION _
ft. ft.
3073 A n. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER t n livable
Crane Bros. Well Drilling FROM TO DIAMETER THICKr ESS MATERIAL
Company Name p ft. 182 H- 16.25 in SDR 21 JPVC
2021-22169-9-1 1 584 FROM
INNER CASING OR TUBING(geothermal closed-Ina
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑MunicipaliPublie It. fL In.
❑Geothemral(Heating/Cooling Supply) 17Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -I&GROUT
❑hTi tion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n• 20 ft benonite pumped
❑Monitoring ❑Recovery ft. ft.
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 it. fL
❑Experimental Technology El Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks) FROM To I DESCRIPTION color,haranec son/rock type,gridn size etc
0 fL 82 fL Clay
4.Date Well(s)Completed:06-13-2022 Well ID# 82 ft. 955 ft. granite
5a.Well Location: ft. ft.
ft. ft
BH Graning Properties LLC f im
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Dills Cove Road Sylva NC 28779 ft. ft. JUL
Physical Address,City,and Zip ft. ft.
Jackson 7632-86-4757 21.REMARKS s t t t
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.Cer• ation:
N35 23.824 N wo83 19.895 W 7/25/2022
6.Is(are)the well(s): PlPermanent or ❑Temporary SignaturetefCertified 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 MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Brown 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 farm.
23,Site diagram or additional well details:
S.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 ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:955 (ft•) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths i t di erent(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: 0 (ft.) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If Neater level is above casing,use"+"
11.Borehole diameter:6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: '7 24c.For Water Supply and Open-Loop Geothermal Return Welts: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,OR GPD:Copy to DWR,CCPCUA
r� Permit Program,1611 MSC,Raleigh,NC 27699-I
13a.Yield(gpm)3 Method of test:air
611
13b.Disinfection type: Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018