GW1--03315_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
FROM l TO 1 DFRC'RIPTION
Weil..nntrucuir iNu11R: •
ft. rt.
3073-A
ft. n.
NC Well Contractor Certification Number 15.OUTER CASING(for muld-cased wells)OR LINER(if a able)
FROM TO DIAMETER THICKNESS MATERIAL
Crane Bros. Well Drillin4 I•_.- :_ I.. ... :_ I____ IPVC
it f" IDO `- iti.2b •''- ISDR21 IPVC
Company Name
010424-1 16.INNER CASING OR TUBING(geothermal dosed-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.
? Will I Ise!_rho"k weft nsr)r ft. R. in
i i
Water Su Weil: 17.SCREEN
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) R. R, in.
^•end ctrialtCommcr ial I:R1'esidential 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 ORecovery ft. ft.
Injection Well:
•
ft H
❑Aquifer Recharge LiGroundwater Remediation I I -____l
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft,
❑Experimental Technology ❑Subsidence Control ft. ft.
i❑Geulhermal(Closed Loop) ❑Tracer i 20.DRILLING LOG(attach additional sheets if necessary)
0
FROM TO Di
ESCRIPTIONay (color,hardness,sollfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) n 58 ft C
4.Date Well(s)Completed: 3/26/2024 Well ID# 58 ft- 460 ft- granite
5a.Well Location: _ . •
Steven Witherspoon ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. v I J V ; �U 4
1081 Junes Creek Rd. Franklin NC 28734 ft. ft. -- ,. .,;;•.11.
+
it. • .
Physical Address,City,and Zip R• ft [.'. r'_��
Macon 6561579445 21.REMARKS
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degreesiminutes/seconds or decimal degrees: i '
(if well field,one lat/long is sufficient) 22.Certifies n:
35 05.372 N 83 27.660 w 5/28/2024
c ,-(s,._)the well(s): i'i Permanent or r,m_n't e3ar, Signature of Certified Well Contractor Date
By signing this form,I hereby certify 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 known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under el remarks section or on the back of this form.
23.Site diagram or additional well details:
.vu ace .ut iiic .....pagc to provi•i•'additional w .cl r nil uon into
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same ~ • J a.'�>.n c;f � t"'3s� "'r.::""`j ._ _ _
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Overt in Remarks Box).You may also attach additional pages if necessary.
dulled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:460 ( ) Submit this GW-1 within 30 days of well completionper the following:
For,..,,tlti„te wells list all depths if dta (example-rent a1 0.0'and Nall O.1 Y P
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Stadc water level below top of casing:0 (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)
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
I FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
3n Air Permit Program. 1611 MSC.Raleigh.NC 27699-1611
Lim.Yield(glow '' Method of test: '
13b.Disinfection type: Sterilene Amount:
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