GW1-2023-01600_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD(GW4) For Internal Use Only:
1.Well Contractor Information:
Rick Crane -14.WATERZONES-
Well Contractor Name FROM TO DESCRIPTION i
3073.A fL ft. i
ft. ft.
NC Well Contractor Certification Number M OUTER CASING for maltt-cased wells OILUVER If a Ilcnbk
Crane Bros.Well Drilling FROM TO DIMIETER ICKNESS MATERIAL
Company Name 0 ft. 144 f 6.25 In SOR=21 1PVC
05�r13�rle� 16.INNER CASING OR TUBING eothermat closed400
2.Well Construction Permit#: G L22 FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well constnmtioa permits(.e WC,County,State,Variance,etc.) fL R. in.
3.Well Use(check well use): R. & in
Water Supply WeB: 17.SCREEN _
FROM I TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public fL fL is
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Lrdustrial/Commercial MResidential Water Supply(shared) 18.GROUT
01ni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fl 20 benonite primped
[]Monitoring ❑Recovery tt. R.
Injection wen:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attself additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks) FROM I TO DFSCREMON color,hardness somrmic type,grala Mo
0 ft. 44 ft. clay
4.Date Well(s)Completed: 12/15/2022 Well ID# 44 ft- 930 fL granite
So.Well Location: ft. ft. a3
Fontana Lake Estates f` n IF-
Facility/Owner Name Facility IDN(if applicable) R• ft. I
LVLJ
Thomas Thayer 164 Hemlock Ride Bryson City, NC ft. ft. lnfc rr:a;:;1 ?rz, •:inr;�
Physical Address,City,and Zip ft. R. D V.,QJ u'0G
Swain 21.-REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.380 N 083.530 W 2/9/2023
6.Is(are)the well(s): InPermanent or ❑Temporary Signature fCertified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or DNo ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Co Itruction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of file of this record has been provided to the we11 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over,in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCl'IONS
9.Total well depth below land surface:93U (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)
10.Static water level below top of casing:200 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater 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)
RotaryProgram,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
1 Air Permit Program,1611 MSC,Raleigh,NC 27699 1611
13a.Yield(gpm) Method of test:
13b.Disinfection typ,:Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources II Revised 6.6-2018
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