GW1-2022-07035_Well Construction - GW1_20220727

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
FROM I TO DESCRIPTION
Well Contractor Name
3 ft. ft.
073 A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER f a lieable)
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
p tt 44 B• 6.25 1n SDR 21 PVC
Company Name
2015-3211-9-11790 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. I ft. in.
17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public B. fL in
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
[]Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL I EMPLACEMENT METHOD At AMOUNT
Non-Water Supply Well: 0 "' 20 fL benonite pumped
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. fa
❑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 R, H.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if neces!ia
FROM TO DESCRIPTION color,hardness,solUtnck e, ruin size,eta
❑Geothermal(Heating/Cooling Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 44 R' Clay
4.Date Well(s)Completed:05-02-2022 Well ID# 44 ft- 905 ft. granite ��Fl-r-
50.Well Location: ft. ft. ` `
Hoge Properties LLC ft. f. JUL 2 / nv
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Norton Road, Cullowhee, NC ft. ft.
Physical Address,City,and Zip ft. ft. :i�.Jrtl.,fir U''J i"4U' t Wit'-a ii. ✓1`�I
Jackson 7562-79-5452 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.C tifleation:
N35 08.080 N wo83 07.397 W
eAl 7/25/2022
6.Is(are)the well(s): MPermanent or ❑Temporary Sig tune ofCertified Well Contractor Date
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance Wilt
7.Is this a repair to an existing well: ❑Yes or 19No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a copy
If this is a repair,fill out knona well construction infor nialion and explain the nature of the of this record has been provided to the well owner,
repair under 421 remarks 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 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:905 (ft') Submit this GW-1 within 30 days of well completion per the following:
For muldple wells list all depths ifdifferent(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJxnter level is above casing,use"+"
11.Borehole diameter:6.25 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: Rota')
Program,1636 MSC,Raleigh,NC 27699-1636
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) 1 Method of test:a i r
Permit Program,161 I MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018.