GW1-2023-02960_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
3073-A ft. ft.
ft. It.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Ucable
Crane Bros. Well Drilling FROM TO DIAMETER TIHCKNFSS MATERIAL
Company Name p ft. 74 ft. 16.25 in SDR-21 JPVC
051722- 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: P FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) fL fr. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) PJResidential Water Supply(Single) it. It. is
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 IL benonite pumped
❑Monitoring ❑Recovery It. %
Injection Well:
ft. t1.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery El Salinity Barrier FROM I TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. iL
❑Experimental Technology ❑Subsidence Control ft. I It.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardnc saivn,ck type,grains eta
p n. 74 ft. clay
4.Date Well(s)Completed:04-11-2023 Well ID# 74 ft. 305 ft- granite
Sa Well Location: ft. ft. `��• - ..
Raquel Martinez Jimenez ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. APR 2 102
Holly Hills Vista, Franklin, NC 28734- ft. ft. ..n
Physical Address,City,and Zip ft. ft. r�0-^^ U Vizi
Macon 6596907344 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N W , ,,,� 4/17/2023
6.Is(are)the well(s): CJPermanent or ❑Temporary SignatVre of Certified Well Contractor Date
By signing this jonn,I hereby certify that the wvell(s)wvas(were)consimcled in accordance ivith
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fit out known well construction information and explain the nature of the of this record has been provided to the wvell owner.
repair under 421 remarks section or on the back ofthis jonn. 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 I GW-1 is needed Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:305 -(ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wvells list all depths 1fdi,(jerent lararnple-3 a(�1 00'and 2@1001
10.Static water level below top of casing: (tt.) 24a, For All Wells: Original form to Division of Water Resources (DWR),
I10.Stawater tic
is above casing•use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 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 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
On.Yield(gpm) 15 Method of est: i r
Permit Program,1611 MSC,Raleigh,NC 2769971611
t
13b.Disinfection type: Stenlene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018