GW1-2023-02962_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Rick Crane 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3073-A ft. fL
R. fL
NC Well Contractor Certification Number 15.OUTER%ING for multi-eased wells OR LINER if a licable
Crane Bros. Well Drilling FROM 70 DIAMETER THHCKNESS MATERIAL
0 I'L 44 ft 6.25 In- SDR-21 PVC
Company Name -16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:2022-23 1 31-9-1 2083 FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable troll construction permits(i.e.UIC,County,State,Variance,etc,) ft• R. in
3.Well Use(check well use): ft. ft. la
Water Supply Well: 17.SCREEN-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL fa in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft.
in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT•
❑hri ation ❑Wells>100000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL benonite pumped
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. tit.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDlGRAVEL PACK01`20olicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage D. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach:addltioual sheets If necessary)
❑Geothermal(Heatin Coolin Return) []Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardnec wilfrock type,grain Sire eta
0 ft• 44 n• clay
4.Date Well(s)Completed:03-30-2023 Well ID# 44 f< 1280 IL granite
Sa.Well Location:
ft. ft.
Terry&Jamie Parrish a. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
Off pine creek Lake Vista Dr. ft. ft. inyr
Physical Address,City,and Zip ft. ft. t
Jackson 7565-21-8777 "21.REmARK& a .
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 11.657 N8308.563 W 4/17/2023
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6.Is(are)the well(s): t9Permonent or ❑Temporary S goo of Certified Well Contractor Date
By signing this form,I hereby certify'that the ivell(s)tvas(were)constructed in accordance n+ith
7.Is this a repair to an existing weB: ❑Yes or 8No 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out knotvn 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 ofthisform. 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 G W-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 INSTRUCTIONS
9.Total well depth below land surface: 1280 0 )
For multiple wells list all depths ifdfflerent(example-3@200'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 800 (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
If water 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,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water SUM and O en-Loo Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental ealth department o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells roducin over 10000
0 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test;Air
Permit Program,161 l MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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