GW1-2023-00976_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, ft.TO DESCRIPTION
Crane Bros.Well Drilling
rt. rt.
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER it a Rcable
3073-A FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 140 It- 6.25 In. SDR-21 JPVC
2020-18396-9-11574 16.INNER CASING OR TUBING enthermatclosed-loo
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 11. ft. in.
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft• ft
❑hrdustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
DIrrigation ❑Wells>100.000 GPD FROM I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- Benonite Pumped
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a Ilcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL _ EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology []Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
[]Geothermal(Heating/Cooling Retain) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soulrock o sire,etc.
�1�f
0 ft. 40 ft clay
4.Date Well(s)Completed: 12-1-22 Weil ID# 40 ft 1330 fL granite
Sa.Well Location: ft. ft. ; +� •�..
William O. Osburn ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
JAN Cat's Paw ft. ft -
Physical Address,City,and Zip ft. ft. 4lektc 1 ri G1-%z •'9 Una
Sylva NC 7534-90-5374 21.REMARKS
Coun 0Er- �j Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer $ tion:
N w C/- 1/12/2023
6.Is(are)the well(s): I,Permanent or ❑Temporary Signature VCertified Well Contractor Date
By signing this form,I hereby certify that the xrll(s)tvas(were)constructed in accordance with
7.Is this a repair to an existing well: []Yes or 8No ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,JNI out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back oftids 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: 1330 (ft.)
For multiple wells list all depths ifdierent(example-3@200'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10. 24a. For All Wells: Original form to Division of Water Resources (DR),
/f u
ti nm level Static lev el is above rasing,use"+"water level below top of casing: W
(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(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Supg1 and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental ea th 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)O Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6b2018