_Well Construction - GW1_20230320 (47)

WALL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES .
Well Contractor Name FROM TO DESCRIPTION
ft. ft. i
3073-A ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 88 ft• 6.25 in' SDR;21 PVC
111522-P 16.INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN -
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. 1
❑Geothermal(Heating/Cooling Supply) I Residential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
,Non-Water Supply Well: 0 B' 20 D• be,^,onite pumping
❑Monitoring ❑Recovery fL ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. rt.
❑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(cobs,hardness son/rock type,grain sure.etc.)
0 ft. 88 ft. clay
4.Date Well(s)Completed:2/20/2023 Well-ID# 88 ft• 1005 ft. granite
5a.Well Location: ft. ft.
Charles Hulme _ .. ?"7-7,.,",
ft. ft. _
Facility/Owner Name Facility ID#(if applicable)
ft. rt. '-.ka..�<.s I-s E nn...�,i...i
596 Icenhower Dr. Franklin, NC 28734 ft. MAR ?. 0 2Q21
Physical Address,City,and Zip ft. ft.
Macon 6569719779 21.REi1fARKS 7m7z•" :-:7
let; ;,.: DWQ/30-C4County Parcel Identification No,(PIN)
5b.Latitude and longitude in degrees/urinute'slseconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
35 17.594 N 083 27.876 W t u 1'� � 3/14/2023
6.is(are)the well(s): ClPermnnent or ❑Temporary Sigaa £Certified Well Contractor I , Date
By signing this form,I hereby cernfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L'!No 1SA 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 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:
S.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 allach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1005 (ft.)
For multiple wells list all depths 11-different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below of casing: 100 - (ft,) 24a. For AU Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699=1617
If water level is above casing,use top
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 Supply and Open-Loop 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) 1/2 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b,Dicinfeetton type: Sterilene Atiteuo►_:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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