_Well Construction - GW1_20230320 (57)

WELL CONSTRUCTiON RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
Well Contractor Name FROM I TO f DESCRIPTION
3073-A ft. ft
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for mutt!eased wells UR LINER if n Iicnbk
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 164 ft 6.25 In. SDR!21 JPVC
16,INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#.2020 FROM TOI DIAMETER- I THICKNESS I 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: R SCREEN re ETE_ ES M,TERT
FROM TO D_4L__.P SLUT SIZE iHSCK.N__S .dA 4L
❑Agricultural ❑Municipal/Publia ft. ft. im
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. R.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
OInigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 fL benonite pumping
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. tit.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
OAquifer Test ❑StormwaterDrainage ft. ft
[]Experimental Technology ❑Subsidence Control ft. [L
10Gcothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(HeatinglCooling Return) []Other(explain under#21 Remarks) FROM To I DESCRIPTION color,hardness samrock type,grain size,etc.)
0 rt. 64 rt. clay
4.Date Well(s)Completed: o��0�202� Well ID#`a""z"sit s2 64 ft- 280 it. granite
5a.Well Location: ft. ft.
RRL Management&Consu. f• ft �" ' s' T'
'�..._.
Facility/Owner Name Facility IDII(if applicable) ft. ft b t J iS' a
Ben Cook Road Sylva, NC 28779 ft. ft. AK 2 a
Physical Address,City,and Zip ft. R.
Jackson 7640-50-6508 21.REMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreek/minutes/setouds or decimal degrees:
(if well Geld,one Iattlong is sufficient) 22.Cc r'[cation:
35 19.611 N 083 12.418 W 3/14/2023
6.Is(are)the well(s): L'iPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(ivere)constructed in accordance Writ
7.Is this a repair to an existing well: ❑Yes or ISNo ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifihls is a repair,fill 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 of this form. 23.Site diagram or additional well details:
S.For GeoDrobe/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 I 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 hand surface:280 (ft-) Submit this GW-1 within 30 days of well completion per the following:
For mulit ele wseils list all depths if different(evample-3@200'and 2@100)
1 ?Aa. For All Welle: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ' (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if ivurer level is above casing,rise"+"
11.Borehole diameter:6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Su 1 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 in tolled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test:.Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018