GW1--00333_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1 ,
1.Well Contractor Information: 1
Rick Crane 14.•WATERZONES . - ._ -
Well Contractor-Namc FROM TO DESCRIPTION
H. ft.
3073-A
it. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if licable)
Crane Bros. Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft* 67 ft- 6.25 ! i"' SDR-21 PVC ,
Company Name
021223-P 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.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) itResidential Water Supply(single) g• ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT • . •
❑Irrigation ❑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 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additionarsheets if necessary)- • ; ' - - -
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soWrock type grain slzc,etc.)
0 ft, 67 ft Clay
4.Date Well(s)Completed: 11/20/2023 Well ID# 67 ft. 1405 ft- granite
5a.Well Location: ft ft: of ;a�L
F A
Bulmaro Morgado Sanchez ft. ft. l 'y+�--`4w"61....-r V
Facility/Owner Name Facility ID#(if applicable) it, it. j/A I\1 1 !+ 2024
244 Jay Lane, Franklin,NC 28734 ft. fL
Physical Address,City,and Zipt n c. ,i.:' 1 w
Ys ft. ft. EMO.i.30G
Macon 6596020979 31.REDiARIC3.
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.Ce ' cation:
N W
_,C/Z.) &tr&Pit-e--) 1/3/2024
6.Is(are)the well(s): OPermanent or OTemporary Signet of Certified Well Contractor Date
By signing this form,'hereby certifythat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A 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 foram. 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 INSTRUCTIONS
9.Total well depth below land surface: 1405 (ft.)
For multiple wells list all depths if different(example-3®200'and 2p100) Submit this GW-1 within 30 day i of well completion per the following:
24a, For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1 0 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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 producing'over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)6 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
1
13b.Disinfection type: Sterilene Amount:
.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018