GW1-2022-08957_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
FROM TO DESCRIPTION I
We1lContractorNamv ft. ft. I '
3073-A n.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells UR LINER if n Ileable
Crane Bros. Well Drilling FROM TO DIAMETER TffiCKNEs3 MATERIAL
Company Name 0 ft. 1118 ft- 16.25 1n SDR-21 JPVC
061221-P -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.) fL ft. I i
3.Well Use(check well use): ft. ft. in
Water Supply Well: :17..SCREEN
FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public h, ft. br
❑Geothemlal(Heating/Cooling Supply) InResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 48.GROUT'
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 benonite pumped
❑Monitoring- ❑Recovery ft. ft.
Injection Well:
ft. tt
❑Aquifer Recharge _ ❑GroundwaterRemediation ---- .19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage R n•
❑Experimental Technology []Subsidence Control % I fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary) -
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1
FROM TO DESCR1PT10x color,hardness,walrock type,Main die eta
0 fL 118 ft• clay
4.Date Well(s)Completed:08-15-2022 Well ID# 118 H- 905 ft. granite
Sa.Well Location: tt. it.
Martin Wright n• ft. 'f __
Facility/Owner Name Facility lD#(ifapplicable) ft. f6 -1" -.y ge
175 Hidden Hollow Lane Otto NC 28763 ft. ft. F I
Physical Address,City,and Zip ft. ft.
Macon 6499012856 21.REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) 22. rtification:
35 01. 334 N8322.569 W � 9/13/2022
6.Is(are)the well(s): [!)Permanent or ❑Temporary Signature of Certified Well Contractor Date
I
By signing thisform,I hereby certify that the well(s)was(wI'llere)constructed in accordance ivith
7.Is this a repair to an existing well: []Yes or ONo 15A NCAC 02C.0100 or 15A NC,1C 01C.0200!Nell i onstruction Stmudards and that a copy
Ifthis is a repair,fill out known well construction Information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remark 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-)GW-1 is needed Indicate TOTAL NUMBER of wells _ (add'See Over,in Remarks Box).You may also attach additional pages ifnecessary. _
`filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:905 (n') Submit this GW-1 within 30 per days of well completion the following:
For multiple wells list all depths ifdierent(example-3Q200'and 2@100) y p p g'
10.Static water level below top of casing: 100 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifutiter 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,
I .1636 MSC,Raleigh,NC 27699-16361
12.Well construction method: '7 24c.For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county envtromneatal health department of the county w ere installed
i .
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells Droducina over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)5 Method of test:Ai r Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 6.6-2018