GW1-2022-07041_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 I TO I DESCRIPTION
ft. ft.
3073 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINEIR if a Iicabla
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 it- 120 ft• 6.25 1- SDR 21 PVC
Company Name 16.INNER CASING OR TUBING eothermal clo5ed400
2.Well Construction Permit#: 201 9-1 4005-9-1 1 840 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
FRO31 TO DIAMETER SLOTSI7,E THICKNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. In.
[]Geothermal(Heating/Cooling Supply) 19Residential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 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 ft. fL
❑Experimental Technology ❑Subsidence Control ft. IL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness solUmek type, rain slm,etc.
0 It- 120 fL Clay
06-22-2022 ,a; C`"
4.Date Well(s) ft'(s)Completed: Well1D# 120 605 granite TMr' N,+,�,
5a.Well Location: ft. ft.
JUL Devin Mason ft. ft. -
Facility/Owner Name Facility ID#(if applicable) ft. ft'
100 Hidden Springs Rd. Whittier, NC 28789
Physical Address,City,and Zip ft. ft.
Jackson 7613-78-8942 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degreWndnutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C fication.
N35 25.757 N wo83 18.311 W /c"'X _ 7/25/2022
6.Is(are)the well(s): PJPermanent or ❑Temporary igna ure of Certified well Contractor Date
By signing this form,i hereby certify that the well(s)war(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
Iflhis is a repair,fill out knoavt well construction information and explain the nature ofthe 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 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 i 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:605 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For mudtiple wells list all depths ifdierent(example-3@200'and 2@100)
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
Ifunter level is above casing,use•'+••
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rota Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 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 instal ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)4 Method of test:.a r
Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: Sterilene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018