GW1-2022-07042_Well Construction - GW1_20220727

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
FROM I TO DFSCRIPTION
Well Contractor Name
ft, ft.
3073_A ft. ft.
NC Well Contractor Certification Number 15.0UTER CASING for multi-cased wells OR LINER If a Iicable
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 45 ft 6.25 1n SDR 21 IPVC
Company Name
2021-22397-9-11780 16.INNER CASING OR TUBING eothermal closed-loop)
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. ft. is
Water Supply Well: FROM�E TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural OMunicipal/Public ft. H. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROltf I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 20 fL benonite pumped
❑Monitoring ❑Recovery ft. B.
Injection Well:
❑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. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necesna
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soll/rock t1w,Crain Sire,ctc
0 It• 45 R• Clay
4.Date Well(s)Completed:07-05-2022 Well ID# 45 IL 305 It. granite
So.Welt Location: ft. ft. `
TheBroadwayGroup ft. ft. JUL 2 2a
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Skyland Dr. & Buff Creek Road ft. ft.
Physical Address,City,and Zip ft. fL e.v�i:di4t+tu at'l1 ' `J�'�I•II
CT
Jackson 7662-18-0725 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Ce tiflcation:
N35 24.397 N wo83 09.554 w 9 _ 7/25/2022
6.Is(ore)the well(s): (nPermanent or ❑Temporary S tth of Certified Well Contractor Date
By signing this form,I hereby certify that the s ell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo JSA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out/mo,mm 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 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 OW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMIWAL INSTRUCTIONS
9.Total well depth below land surface: 305 (fI') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100)
10.Statle water level below top of casing:20 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If u reter level is above casing.use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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 O en-Loa Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental healthdepartment 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)20 Method of test:a I r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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