GW1-2023-00978_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ^R
Rick Crane 14.WATER ZONES t'{er '
Well Contractor Name FROM ft. rt.TO DESCRIPTION
�Crane Bros.Well Drilling
rr. rft. Z0Z3
NC Well Contractor Certification Number 15.OUTER CASING for mu►tl-cased wells OR LINER if a Ucable ' , �g U1111
3073-A FROM TO DLll1fETER THICKNESS MATE '
0 ft- 40 ft- 6.25 1n SDR-21 JPVC
Company Name
2018-11299-9-11928 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) M fL In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: -17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public ft. fL In.
❑Geothermal(Heating/Cooling Supply) GResidential Water Supply(single) n• fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft Benonite Pumped
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage fa ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILL LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1
FROM TO I DESCRIPTION color•hardness soWrock type,grains etc
0 ft 40 ft clay
4.Date Well(s)Completed:09-13-22 wel1ID# 40 ft• 1200 ft- granite
5a.Well Location: ft. ft.
Jocelyn Hills ft. rL
Facility/Owner Name Facility ID#(ifapplicable) ft, ft'
521 Walking Stick Trail ft. ft.
Physical Address,City,and Zip ft. ft.
Cullowhee NC 7556-61-0583 21.REMARKS =
County"!Ja i I/ �, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld,one lat/long is sufficient) 2AC, ,,fitin;
wo83 16.585 N N35 2 198 w 1/12/2023
6.Is(are)the well(s): t9Permanent or ❑Temporary SignaturtkofCertified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or tlNo 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,f ll out known well construction information and explain the nature of the of this record has been provided to the well owner, j
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 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: 1200 (ft.)
For multiple wells list all depths ifd�erent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:0 (th) 24a. For All Welts: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,rase"+^ 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 Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducint over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)O Method of test:Air
Permit Program,161 I MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018