GW1-2022-01217_Well Construction - GW1_20220103

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RD I
ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3073 A
1.WELL CONTRACTOR: g. WATER ZONES(depth):
Rick Crane Top Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
Crane Bros. Well Drillina Top Bottom Top Bottom
Well Contractor Company Name
Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address Topo Bottom 24 Ft.6.25 SDR 2 PVC
Franklin NC 28734 Top Bottom Ft.
City or Town State Zip Code Top Bottom i t.
( 828 ) 524-4976
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 Ft,benonite pumped
WELL CONSTRUCTION PERMIT#101521-P : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(f applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)7540660318
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED 12-20-2021 Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY: Hiahlands COUNTYMacon Top Bottom Ft.
420 Crowe Drive Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other 11.DRILLING LOG
LATITUDE 35 °a tz2.0000 Top Bottom Formation Description
_ "DMS OR 3X.XXXXXXXXX DD 0 /24 iClav
LONGITUDE83 Imo°tt -so7.0000 °DMS OR 7X.XXXXXXXXX DD : 24 /705 granite
Latitude/longitude source: NOS (]Topographic map
(location of well must be shown on a USGS topo map andattached to l
this form if not using GPS)
5.WELL OWNER / JQN 0 3 2029
John & Maiorie Crowe /
Owner Name / wwo
420 Crowe Drive / E ,�t1rRIN( iiP`
Street Address
Hiahlands NC 28713 /
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:705
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 80 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PRO D TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface-
'Top of casing terminated aUor below land surface may require 12-29-2021
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 3 METHOD OF TESTAir Rick Crane f
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON1CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a
1617 Mail Service Center,Raleigh,INC 27699-161,Phone:[phone] Rev.2/09
1 .