GW1--04702_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES -
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3073-A ft. fr.
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. 60 ft. 6.25 In. SDR-21 PVC
111022-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): B. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CIResidential Water Supply(single) ft. ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f'• 20 fL benonite pumped _
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. fit.
❑Aquifer Recharge ❑Groundwater Rcmediation 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 OSubsidence Control ft. R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size Ma)
0 ft. 60 ft. Clay
4.Date Well(s)Completed:06/05/2023 Well ID# 60 ft. 455 ft. granite
5a.Well Location: ft. ft.
William Nemeth ft. ft. F e c.c f"i 1/t-
Facility/Owner Name Facility!DI/(if applicable) ft. ft.
2275 Corbin Rd., Franklin, NC 28734 ft. ft. JUL r 4 2023
Physical Address.City,and Zip ft. ft. r am-
Macon 7516358407 21.REMARKS �r"f`^i^ P
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 13.599 N 083 18.579 W 7/20/2023
6.Is(are)the well(s): l Permanent or :Temporary Sig use o 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 ONo 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200'Yell 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:
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:455 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii different(example-3@200'and 2@l00')
10.Static water level below top of casing 7 v (fL 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water 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.)
Rotas 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)30 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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