GW1-2023-01599_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES,
WeUCoatmetorName FROM TO DESCRIPTION^ I I
3 ft. II
073-A
NC Well Contractor Certification Number -15 OUTER CASING for Tgti cased wells OR LINER if a licable
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 86 ft- 6.25 In. SDR-21 JPVC
:-16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 07-02-19 ft- ft. in.
3.Well Use(check well use):
CREENz
Water Supply Well: FROM TO DIAI4IETER SLOT SIZE THICKNESS I MATERIAL"
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. In.
❑lndustrial/Commercial InResidential Water Supply(shared) 18.GROUT ._
[Irrigation ❑Wells>100 000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 f6 benonite pumped
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. tL
❑Aquifer Recharge ❑Groundwater Remediation
49:SANDlGRAVEL PACK ifapplicable)
'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It. ft.
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach additional sheets If necessary)
[]Geothermal(Heatin Coolin Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardo soft/rock type,VnIn size,etc
0 IL 86 IL clay
4.Date Well(s)Completed:01-09-2023 Well ID# 86 ft• 905 ft- granite
Sa.Well Location:
Fawn Cove Lane ft• ft
Facility/Owner Name Facility W#(if applicable) ft. ft
Ashok Ramaswany ft. ft. _
Physical Address,City.and Zip B. ft.
Swain .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.Ce cation:
35 21.949 N08328.894 W 2/9/2023
6.Is(are)the Well(s): ItPermadent or ❑Temporary Signature fCertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONO 15A NCAC 02C.0100 or 15A 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 021 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:905 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijd�erent(erarnple-3@200'and 1@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifi Static water level below top of casing:20 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
+ester level is above casing,use"+"
11.Borehole diameter:6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: 24c.For Water Sup 1 and O eo-Loo Geothermal Return Wells:Copy to the
av
(i.e.auger,rotary,cable,direct push,etc.) county etronmental heap department or the county where installed
FOR WATER SUPPLY WELLS ONLY: I'
24d.For Water Wells Droducine over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) t
Seepage Method of tes:Air
Permit Program,1611 MSC,Raleigh,NC 27699,-1611
13b.Disinfection type:Sterilene A.out:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6 6 2018