GW1-2022-07174_Well Construction - GW1_20220729

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 i.
3073-A R.
ft. I ft,
NC Well Contractor Certification Number 15.OUTER CASING for multi-euM wells OR LINER a Itnble
Crane Bros. Well Drilling FROM TO DIAMETER TH,CKIVFSS MATERIAL
Company Name 0 tt 84 fL 16.25 1° SDR21 JPVC
020922-h 16.INNER CASING OR TUBING eothermat clasedaoo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) It. f 10
3.Well Use(check well use): R. IL In.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I sLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubiic tL fL In.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) R R in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑]rii tion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 " 20 n' benonite puh1ped
❑Monitoring ❑Recovery [L fL
Injection Well:
ft. [L
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK Irapplicable)
❑Aquifer-Storage and Recovery ❑Salinity Barrier FROM I To I MATERIAL EMPLACEMEw METHOD
❑Aquifer Test ❑Stormwater Drainage ft. IL
❑Experimental Technology []Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheen if necessary)
FROM TO DESCRIMON color,hardness,eeWroek a da eta
❑Gcothemral(Heating/CoolingReturn) ❑Other(explain under#21 Remarks
0 fL 84 fL Clay
4.Date Well(s)Completed:05-03-2022 Well� 84 iL 305 n- granite
5a.Well Location:
Joseph Sunderhaus rt
Facility/Owner Name Facility ID#(ifapplicabie) tt. tL
592 Millbrook Cove, Franklin, NC 28734 "• ft. n
Physical Address,City,and Zip It. R• J U L 2 9 2022
Macon 6564976191 21.REMARKS
County Parcel Identification No.(PIN) in(orlsttOn Proce amelg dull
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laOong is sufficient) 22.Ce eation:
N35 10.336 N W083 27.168 w C 7/26/2022
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signatute of Certified Well Contractor Date
By signing this form•I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 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#11 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 providei additional well construction info
construction,only l 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:305 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
10.Static water level below top of casing:60 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is abate 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(RJC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Su and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environments heap apartment o the county ere install
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roduein over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test:Air Permit Program,161 l MSC,Raleigh,NC 276 9-1611
i
13b.Disinfection type:Stenlene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018