GW1--01940_Well Construction - GW1_20240325

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information: !
Rick Crane 14.WATER ZONES -
Well Contractor Name FROM TO I DESCRIPTION
3073-A
fit. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if tip livable)
Crane Bros Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 R• 69 n• 6.25 in• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed leap)
q
2.Well Construction Permit#: 1 10323-r FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction pcennits(i.e.UIC.County,State,Variance,etc.) It. IL . in.
3.Well Use(check well use): ft. rt. in.
Water Supply Well: 17.SCREEN
lip 5 FROM. TO DIAMETER SLOT SIZE THICKNESS MATERIAL 1
❑Agricultural ❑Municipal/Public ft, ft. in.
uGeothermal(Heating/Cooling Supply) LiResidential Water Supply(single) fL rt. hi.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT . - - - . -
flirrigation r1Wells>100,000 GPD _-F_OM TO R MATERIAL EMPLACEMENT METHOD&AMOUNT
Nun-Water Supply Well: 0 ft. 20 ft• Ibenonite pumped 1
❑Monitoring ❑Recovery ft. ft. 1
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ! TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test. ❑Stormwater Drainage ft. ft.
❑lwxperimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING.LOG(attach additional sheets if necessary);
FROM I TO DESCRIPTION(color,hardness,soil:rode type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21-Remarks)
0 ft. 69 ft. clay
4.Date Well(s)Completed: 1/12/2024 Well ID# 69 ft• 805 ft• granite .
ft. ft.
,5a.Well Location:
Brend Oslund _ ___ ft. ft. .', ` ,
- ft. 1 ft. 1''� ,.,.1,L. ?� a r. 1
Facility/Owner Name Facility ID;(if applicable)
Ginger Tree Lane, Franklin, NC 28734 It. ft. MAR ;roc.
•
Physical Address,City,and Zip C �+ D ft. lnf•,---.�-!t.., --,.
Macon 6582968656 21.REMARKS -.C<. • ."_ ', ,"".�w U:�'
YlJ1Jj
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Int/long is sufficient) 22. riifcation: , f�j¢/j
WIN I
3/13/2024
6.Is(are)the well(s): OPermanent or .❑Temporary Signal of Certified Well Contractor Date
By signing this form,I hereby verily)'that 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 blown well construction information and explain the nature of the of this record has been provided to the well nsmer._
repair under#21 remaria 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 (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:805 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@2200'and 2@ 100')
10.Static level below top of casing: 100 (fit.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f -Statical water a level
e el below
op" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells:Copy to DWR,-Underground Injection Control(RIC)
11.Borehole diameter 6'25 (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Wellconstruction method: Rotary
24e.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) Method of test:Air
3 Permit Program,1611 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