GW1-2023-00972_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
Well Contractor Name FROM ft. TO DESCRIPTION
ft.
Crane Bros.Well Drilling
ft. tc I
NC Well Contractor Certification Number 15.OUTER CASING: for multltased wells OR LINER tf a Gcable
3073-A FROM TO DIAMETER THICKNESS MATERLII
Company Name 0 i'L 30 II 6.25 In SDR-21 PVC
111320- 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: p FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,erc.) ft. ft. In.
3.Well Use(check well use): ft. fL In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SI7E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. fL In.
❑Industrial(Commercial ❑Residential Water Supply(shared) 18.GROUT
Ofirigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It• 20 IL Benonite Pumped
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ira licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage H tt
❑Experimental Technology ❑Subsidence Control ft. tt
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets H necessary)
FROM TO DESCRH'TION color,hardness,saWtock e, rein size,eta
El Geothermal(Hearin Coolin Return) ❑Other(explain under#21 Remarks) FROM
It• 30 n' Clay
4.Date Well(s)Completed: 11-21-22 wen lD# 30 It• 705 It• granite
5a.Well Location: ft. ft. 9 d
Douglas Exley ft. f•
Facility/Owner Name Facility ID#(if applicable) ft. fL J A N 8 2023
lotla View ft. ft.
UFA
Physical Address,City,and Zip ft. ft. '
Franklin NC 28734 6586004237 21.REMARKS
County urn
o C o .--1 Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld,one lat/long is sufficient) 22, titleation:
N w � 1/12/2023
6.Is(ore)the well(s): MPermanent or ❑Temporary Signalum of Certified Well Contractor Dare
By signing this form,I hereby certify that the nell(s)was(were)constructed in accordance ndth
7.Is this a repair to an existing well: ❑Yes or PJNo 15A NCAC 02C.0100 or ISA 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 ofthis record has been provided to the well onwer.
repair under 921 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.
hued' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 705 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(trample-3@200'and 2@I00)
10.Static water level below top of casing: 100 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifnrrter 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(IUC)
Rotary(in,) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 24c.For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental hea t department of the county where ins&l ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)6 Method of test: Ir
13b.Disinfection type: Sterllene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018