GW1-2023-00974_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, n.TO DESCRIPTION
Crane Bros.Well Drilling
ft. IL
NC Well Contractor Certification Number 15.OUTER CASING far muiti-oased wells UR LINER i[a Rcable
3073-A FROM TO DIAMETER THICKI'iFSS MATERIAL
0 ft• 120 fL 6.25 '" SDR-21 PVC
Company Name
020122- 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: r) FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well consaroctiou permits(i.e.UIC,County,State,Variance,etc.) ft I n. in.
3.Well Use(check well use): ft' I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT S17.E THICKNESS MAMOU.NT
❑Agricultural ❑Municipal/Public ft. fa in.
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METH
Non-Water Supply Well: 0 ft 20 ft• Benonite Pumped
❑Monitoring ❑Recovery ft. fL
Injection Well:
n. rL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft, I ft.
❑Experimental Technology ❑Subsidence Control ft. I ft
❑Geothermal(Closed Loop) ❑Tracer -20.DRILLING LOG attach addldonal sheets If necessary)
❑Geothermal(Heatin Coolin Return) ❑Other(explain under#21 Remarks) FROM To I DESCRIPTION color,hardness,wivrock type,grain sim,eta
0 f4 120 fL clay
4.Date Well(s)Completed:9-22-22 Well ID# 120 ft 655 f4 granite
5a.Well Location: ft. ft. F6- _
Joel Anderson ft. ft. 1
Facility/Owner Name Facility ID#(if applicable) ft. fL
Lakey Creek Road ft. % IntoPpfk an Pr;nzoo ng u
Physical Address,City,and Zip ft. ft
Franklin NC 28734 6579434170 21.REMARKS
County m/1 i i C1/1 Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well Geld,one IatAong is sufficient) 22.WC 'ication;
3502.10 N8322.25 W
1/12/2023
6.Is(are)the well(s): OPermanent or ❑Temporary SignaturFof Certified Well Contractor Date
By signing this form,I hereby certify that the i ell(s)tvas(were)constructed in accordance with
7.Is this a repair to an existing well: []Yes or LINO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair•Jill out known well construction information and explain the nature of the ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis 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:655 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijdi f'erent(example-3 200'and 2@100)
100 24s. For All Wells: Original form to Division of Water Resources (DWR),
Ijwwrer level is above casing,use"+"
f Static water level below top of casing: (ft.) 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)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Su ' and O en-Lon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental ealt 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) 15 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018