GW1-2022-08958_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Rick Crane 14:WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION,
3073-A ft
e. fL f
NC Well Contractor Certification Number 15.OUTER CASING for mulft cased wells OR LINER If a licable
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 iL 24 16.25 i" SDR-21 JPVC
2022-22634-9-11768 .16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in
3.Well Use(check well use): ft' it. in.
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public M fL In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n• fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT': l+
❑Itri ation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weil: 0 IL 20 ft. benonite pumped
❑Monitoring ❑Recovery R. ft.
Injection Wen: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK If a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stortnwater Drainage ft. ft.
❑Experimental Technology []Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other("plain under#21 Remarks) FROM I TO DESCRIPTION color,hardaea soi0rock type,aniln size,eta
0 iL 24 't clay
4.Date Well(s)Completed:08-18-2022 Well ID# 24 ft- 785 ft. granite
5a.Well Location:
Elizabeth Morris n. ft.
Facility/Owner Name Facility ID#(ifapplicable) D. fL 'r-�;'� ^ll` .I'
P.O. Box 1816 Palatka FI 32178 ft. ft.
Physical Address.City,and Lip ft. fL E P
Jackson 7544-80-6717 -21:REMARKS -
County PorcelldemificationNo.(PIN) IRiviinr:ne3il i ri.C?a^.,.':,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.C rtification;
N W 9/13/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Si tune of Certified Well Contractor Date
By signing this form,I hereby certify that the weil(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1!lNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and[flat a copy
Ifthis is a repair,fill our known well construction information and explain the nature ofthe ofthis 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 ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:785 (ft.) 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)
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
Ifivater level is above casing,use"+"
11.Borehole diameter:6.25 (�) 24b.For Infection Wells:Copy to DWR,Underground injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Su 1 and O en-Lao Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental ealt department o the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prod ucine over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)5 Method of test•Ai r Permit Program,1611 MSC,Raleigh,NC 2769 i-1611
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13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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