GW1-2022-08959_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �
Rick Crane 14.WATERZONEs.. r .
Well Contractor Name FROM I TO T DESCRIPTION I `
3073-A i
NC Well Contmetor Certification Number 15.OUTER CASING for mule-cased wells UR LINER if a ihcable -
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 it 84 ft 6.25 in SDR-21 PVC
2022-22733-9-11 861 -16.INNER CASING OR TUBING eothermal clo$ed400 -
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable it-ell construction permits(I.e.UIC,County,State Variance,etc.) ft. IL in.
3.Well Use(check well use): ft• fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMTER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaMblic R. fL In.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R. R. in.
❑Industrial)Commercial ❑Residential Water Supply(shared) I&GROUT
[]Irrigation ❑Wells>100,000 GPD FROM 170 1 MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 H. benonite pumped
❑Monitoring ❑Recovery ft. ft.
Injection Welt:
uifcr Recharge R. ft
❑A q urge ❑Groundwater Remediation
Ifs applicable 19.SAND/GRAVEL PACK wble
❑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) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION cobr,hardness,solumch n she eta
0 ft 84 ft clay
4.Date Well(s)Completed:07-27-2022 Well ID# 84 tt 930 tt• granite
Sa.Well Location: R. ft. _
Dallas Ray Crowe R• ft. -`� � ��.: '�y f=;D
Facility/Owner Name Facility ID#(ifapplicable) R, ft.
SEP
780 Ashe Loop Rd Sylva, NC 28779 ft n
Physical Address,City,and Zip ft. tL
Jackson 7613-33-7502 21•REMARKS '„ ,^-.,, nil
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Ce fieation:
35 24.828 N8319.080 W ,
9/13/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Sigmidwo of Certified well Contractor Date
By signing this form,I hereby certify that the well(s)wan(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.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 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 Nvells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:930 00 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all deprits ifdierent(example-3©200'and 2Q100�
250 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijuater level is above casing,use f Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
11.Borehole diameter:6.25 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rota Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ry 24c.For Water Supply and Open�-Lo()D 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:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699.1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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