GW1-2022-07036_Well Construction - GW1_20220727

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3073 A R. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LIDIER f a livable
Crane Bros. Well Drilling FxD�I TO DIAMETER THICKNESS MATERIAL
0 ft- 24 ft- 6.25 in SDR 21 PVC
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:2021-22276-9-11855 FROM I TO I DIAMETER I THICKNESS1 MATERIAL
List all applicable well consnvction permits(i.e.UIC,County,State,Valiance,etc.) ft. R. in
3.Well Use(check well use): R. R in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SI7E I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. D. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. 111.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 rL lbenonite pumped
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑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 ft•
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Traccr 20.DRILLING LOG attach additional sheets If necesna
❑Geothermal(Heating/Cooling RetReturn) ❑ FROM TO DESCRIPTION(color,horde eolOrmk ea slrc,etc.)Other(explain under#21 Remarks) 0 ft, 24 ft. Clay
4.Date Well(s)Completed:05-17-2022 Well ID# 24 rt• 790 ft' granite
5a.Well Location: ft. ft.
LH Saratay Properties LLC ft. ft. _
-°�
Facility/Owner Name Facility 1D#(if applicable) ft. ft. U y q 7
White side Cove
ft. '?
Physical Address,City,and Zip ft. '
Jackson 7571-52-7041 21.REMARKS
County Parcel Identification No.(PIN) i 11;i 7 J�:I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22. 'flcation:
N35 19. N wo83 0529 W d;&-, , a 7/25/2022
6.Is(are)the well(s): DPermanent or ❑Temporary Sig ure of Certified Well Contractor Date
By signing this form,I hereby certiby that the ivell(s)tvas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out knottm well construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder#21 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:790 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(erantple-3@200'and 2@100)
10.Static water level below top of casing: 100 (it) 24a• For AR Wells: Original form to Division of Water Resources (DWR),
if warer level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 24b.For Injection Wells:Copy to DWR,Underground injection Control(RUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 7(in.) 24c.For Water Su 1 and 02
en-Loa Geothenml Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental heap 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)30 Method of test:air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
Form GW-i North Carolina Department of Environmental Quality-Division of Walor Resources Revised 6-6-2018