GW1--04699_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: '
1.Well Contractor Information:
Rick Crane 14.WATERZONES ,
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3073-A ft. ft.
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased wells)OR LINER(if ap lcable)
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 24 ft. 6.25 In. SDR-21 PVC
Company Name
2020-23404-9-12149 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): R. ft. in.
Water Supply Well: FROM RE E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) lResidential Water Supply(single) ft, ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 R• benonite pumped •
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION
❑Geothermal(Heating/Coolin Return) ❑Other(explain under#21 Remarks) (color,h hardness,soli/rock type,grain size,etc.)
05/23/23 0 ft* 24 ft. Clay
4.Date Well(s)Completed: Well ID# 24 ft. 400 ft. granite _ _ „ .,..t--,
Sa.Well Location: ft. fa R 7 C tz IV�1�
Lawrence Raley ft. rt.
Facility/Owner Name Facility lDf1(if applicable) IL ft. J iJ L 2 4 2023
690 Upsy Daisy LN. Cullowhee, NC 28723 ft. ft. ti.n PT„r tg Ur`R ,
rt. [L itfcvii". Ofl3Ou 3
Physical Address.City,and Zip Ob
Jackson 7563-26-7106 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 fi ation:
N W 7/20/2023
6.Is(are)the well(s): OPermanent or ❑Temporary Signature Certified 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 elNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known welt 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:
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 OW-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:400 (fit') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 200'and 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:0 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:6.25 (in)
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)O Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018