GW1-2023-00975_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 I TO DESCRIPTION
ft. tt.
Crane Bros.Well Drilling
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells UR LINER if a llenble
3073-A FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. 84 ft 6.25 1- SDR-21 JPVC
2022-22755-9-11899 FROM
INNER CASING OR TUBING eothermal cl THICKNESS
2.Well Construction Permit#: FROM TO DIAMETER THICKriRS9 MATERIAL
List all applicable well construction permits fl.e.UIC,Conn%State,Variance,etc,) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS IA MATERL
❑Agricultural ❑MunicipaWublic ft. ft.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. In.
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT
UIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 "' 20 ft Benonite Pumped
❑Monitoring ❑Recovery ft. %
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM70 MATERIAL Eh1PLACEptENT METHOD
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 I TO DESCRIPTION color harsimse willmktype asim.etc
0 ft 84 ft clay
4.Date Well(s)Completed: 9-19-22 Well ID# 84 ft- 455 H• granite
5a.Well Location: ft. ft.
Carrie Swain ft. ft. d "
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
ft. ft. JAN _
Physical Address,City,and Zip ft. ft.
Sylva NC 7620-95-6781 21.REMARKS -
County,-)06"a5n Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22, fication:
N35 02.10 N W083 22.25 W �L k' 1/12/2023
6.Is(are)the well(s): OPermanent or ❑Temporary Signatilre of Certified Well Contractor Date
By signing this form,I hereby cent fy that the well(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or LtNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill 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 Geotherttwl 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:455 (it) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiQereru(example-3 200'and 1@100)
10.Static water level below top of casing: 15 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If H ater 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(IUQ
(in)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method. 24c.For Water Sup 1 and O en-Loo Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environments 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) 5 Method of test: I r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018