GW1-2023-01516_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION I
%
3073.A ft. 4
ft. K. �
NC Well Contractor Certification Number 15.OUTER CASING for inu1N cased wells UR LINER If a Ilcnbte
Crane Bros.Well Drilling FROM TO DL4METER TffiCKNFSS MATERIAL
Company Name 0 ft. 106 ft- 6.25 in SDR-21 JPVC
040722-n .16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: N FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable sell consiniction permits Q.e.UIC,County,State,Variance,etc.) ft• ft. in,
3.Well Use(check well use): ft. ft,
in.
Water Supply Well: 17.SCREEN
FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it, R• In.
❑IndustriaUCommercial MResidential Water Supply(shared) I&GROUT
Ofirigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT bIETIIOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- benonite pumped
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACE51ENT METHOD
❑Aquifer Test ❑Stormwater Drainage fa ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If oecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DFSCRH?TIOx color,hardne somrock c n slzr,cta
0 fL 106 ft- clay
4.Date Well(s)Completed: 11/02/2022 Well ID# 106 ft- 505 ft• granite
Sa.Well Location: <, e _�, 'its p
Chapel Cove ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL L 1
ft. ft.
Thomas Cwik
ff. r^•Ia'Q'^
u
Physical Address.City,and Zip % C..;L.l C 7 •
Macon 6593253486 -21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.14294 N 083.35882- W
C'rq" 2/9/2023
6.Is(are)the well(s): 19Permanent or ❑Temporary �i of Certified well Contractor I Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Arrown well construction information and eAplah r 1/10 nature of the of this record has been provided to the well owner,
repair tinder#21 remarks section or on the back of this 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:505 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
24a, For All Wells: Original form to Division of Water Resources (DWR),
#'water level!s above casing,use"+"Static water level below top of casing: 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Tj
11.Borehole diameter:6.25 (ID) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(RUC)
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 healt department of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000IGPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 15 Method of test: jr
13b.DlshhfectIoD type: Sterilene Amount:
i
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Form GW-I North Carolina Department ofEavironmental Quality-Division of Water Resources I Revised 6-6-2018