GW1-2022-08956_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES-
WellContractor Name FROM TO DESCRIPTION I
3073-A ft. ft.
ft. ft.
NC Well Contractor Certification Number -15.OUTER CASING for multi-eased wills)' LINER if a Rcable -
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 45 f6 6.25 1 ISM-21 PVC
Company Name _16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#;_121821-P FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable will construction permits(i.e.UIC,County;Stale,Variance•etc.) it. ft. In
3.Well Use(check well use): ft. ft. hL i
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaltPublic ft. ft• in
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❑Geothermal(11wting(Cooling Supply) InResidential Water Supply(single) n R,
❑lndustrial/Cornmercial ❑Residential Water Supply(shared) -18.GROUT'
OhTigation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well; 0 ft. 20 IL benonite pumped
❑Monitoring ❑Recovery, a. 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 ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Ttaeer -20.DRILL LOG attach additional sheets If necessary)
❑Geothermal(Heatin Coolin Return) ❑Other(explain under#21 Remarks) FROM To I DESCRIPTION color,hardness,sowrocb type,grain s eta
0 ft. 45 ft- clay
4.Date Well(s)Completed:08-23-2022 Well ID# 45 ft- 505 ft. granite i
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5a.Well Location: B. ft. o, f
Charles Blanchard B. ft.
Facility/Owner Name Facility 1D#(if applicable)
ft. to
609 Golf Course Rd. Waynesville, NC 28786 ft. H. -
Physical Address.City,and Zip fL ft
Macon 7515892876 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C cation:
35 02.779 N8317.606 w W, e 9/13/2022
6.Is(ore)the well(s): MPermanent or ❑Temporary SignatukLfifCertified Well Contractor Date
By signing this farm,I hereby certify that the vvefts)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo ISA NCAC 01C.0100 or ISA NCAC 01C.0100 Well i oristr tcnon 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#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 Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24•SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:505 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi#"erent(c ranrple-3@200'and 2@100)
10.Static water level below top of casing: 100 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifuater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6.25 (in) 24b.For Iniection Wells:Copy to DWR,Underground injection Control(IUC)
Rota Program,.1636 MSC,Raleigh,NC 27699-1636,
12.Well construction method: 24c.For Water Su i and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental healt department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water R'ells Droducin"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: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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