GW1-2022-08247_Well Construction - GW1_20220530

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v R3 RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 3073 A
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1.WELL CONTRACTOR: � v@. \ p Bottom Top Bottom. WATER B ONES(depth).
Rick Crane �.. To
Well Contractor(Individual)Name 3 0 2022 Top Bottom Top Bottom
Crane Bros.Well Drillina MAY Top Bottom Top Bottom
Well Contractor Company Name ja t r•:' Rh
Itt0063a�,,p; QG Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address Top 0 Bottom 24 Ft.6.25 SDR-2 PVC
Franklin. NC 28734 Top Bottom Ft.
City or Town State Zip Code
( 828 ) 524-4976 : Top Bottom Ft.
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Topo Bottom20 Ft:benonite pumped
WELL CONSTRUCTION PERMIT#2021-21575-9-11651 Top Bottom Ft._ .
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(ff applicable)7565-21-1724 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in... in.
DATE DRILLED4/14/2022 Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM e
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: Cullowhee COUNTYJackson Depth Size Material
Top Bottom Ft.
Lake Vista Dr. Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom F1:.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley []Fiat ❑Ridge ❑Other 11.DRILLING LOG
Top Bottom Formation Description
LATITUDE 35 °11 1 699.0000 "DMS OR 3x.XXXXXXXXX DD ; 0 /24 Clav
LONGITUDE 83 °a •602.0000 -DMS OR 7X.XXXXXXXXX DD 24 /1155 _Granite
Latitude/longitude source: Ef3PS ❑ropographic map /
(location of well must be shown on a USGS topo map andattached to l
this form if not using GPS) l
6.WELL OWNER /
Jim Goldstein j
Owner Name /
5882 NW 23rd Wav
Street Address /
Boca Raton FL 33496 /
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:1155
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO @e
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 600 FT, ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use°+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
ZPR IDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land SurFace`
'Top of casing terminated at/or below land surface may require l 5-27-22
a variance in accordance with 15A NCAC 2C.0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 6 METHOD OF TESTAir Rick Crane
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality- Information Proce-ssing-! Form GW-1a
1ti17 Mail Service Center,=Raleigh,NC 27699-161;Phone: [phone] Rev.2/09
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