GW1--04700_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
Rick Crane 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3073-A f
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Crane Bros. Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 84 fL 6.25 In. SDR-21 PVC
011323-P 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): ft. ft. in.
Water Supply Well: 17.SCREEN-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 IL benonite pumped
:Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. It.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) -
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(cater,hardness roNrock type,Rana btu etc)
0 ft. 84 It. Clay
4.Date Well(s)Completed:04/19/2023 Well ID# 84 ft• 505 IL granite
ft. ft.
Sa.Well Location: r-,"ems.,tir-.•_ •,_
FL Ownership ft. It. \C`= V t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Fred Slagle Rd., Franklin, NC 28734 ft. ft. JUL .? 4 2023
Physical Address.City.and Zip ft. [t. lfllsFir'.Ta lc^Il Prn ?r,13 t;
nit
Macon 6564723555 21.REMARKS - - • GWC,/.1Cr.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Held,one 1at/long is sufficient) 22.Ce cation:
35 09.487 N 083 27.600 w 7/20/2023
6.Is(are)the well(s): PJPermanent or ❑Temporary Sigaat of Certified Welt Contractor Date
By signing this form,I hereby certfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or -itNo 15A NCAC 02C.0100 or ISA 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#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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 if different(example-3@200'and 1@I00'
10.Static water level below top of casing:_150 _- - (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If linter level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:6.25 (in.)
RotaryProgram,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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)20 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
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