_Well Construction - GW1_20230320 (49)

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
-
Well Contractor Name FROM TO DESCRIPTION 1
3073-A ft. ft.ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 51 fL 6.25 in. SDR121 PVC
Company Name 16.INNER CASING OR'TUBING(geothermal closed-loop) -
2.Well Construction Permit#:031922-P FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE i THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. is
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 120 fL beronite pumping
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. it.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal FROM TO DESCRIPTION(colon hardness.soil/rock type,grain size.Mal
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 51 tL clay
4.Date Well(s)Completed:2/28/2023 Well ID# 51 ft. 980 R' granite
5a.Well Location: ft. ft. riT .__,. ' d
Charles Greb ft. ft. .i ````..'r am -,_‘,_-L.a li L--..,,_.,,
ft.
Facility/Owner Name Facility IU#(if applicable)
ft. MAR 2 0 2023
Rose Creek Franklin, NC 28734 ft. ft.
Physical Address,City,and Zip ft. ft. l r: lira-5;:=1 Pr;:-...7,),?.-- no L n 1
Macon 6577756063 21.REMARKS Qt'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degl'eeshuinutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 14.896 N 083 25.856 W I 3/14/2023
6.Is(are)the well(s): !Permanent or ❑Temporary Signs. of Certified Well Contractor Date
By signing this form,thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 21No 1SA NCAC 02C.0100 or 1SA 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#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 OW--1 is needed. Indicate TOTAL NUMBER of wells (arid'See Over'in Remarks Box).You may also attach additional pages it'necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:980 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
1�.Cl 24a. For MI Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing: " (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (in.)
Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: '7 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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)2 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
Disinfection type: Sterilene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018