GW1--04704_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD(GW-1) For Tnternal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3073-A B. ft. , i
ft. ft. j
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
0 ft. 144 ft• 6.25 In. SDR-21 PVC
Company Name
031023-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 ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CIResidential Water Supply(single) f<. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT - . -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft' 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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soli/rock type,grain sere,cu.)
0 ft' 144 ft• Clay
4.Date Well(s)Completed:06/20/2023 Well ID# 144 ft. 655 f`• granite
5a.Well Location: ft. ft.
Wendy Bruessow ft. ft. E(,;E a��=3
Facility/Owner Name Facility ID#(if applicable) ft. ft.
216 Blackberry Ridge, Franklin, NC 28734 ft. ft. JUL 2 4 2023
ft. ft.
Physical Address.City,and Zip 21.REMARKS lnt rr r,_.1'n P rf'. �-,a;,-•�-L 0
Macon 6568971704 iNiCse C}C;
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - - .- - - -
(if well field,one lat/long is sufficient) 22.Ce ' cation:
35 17.105 N 083 27.504 W 7/20/2023
6.Is(are)the well(s): Permanent or ❑Temporary Si 'fur ertified Wel 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 0No ISA 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:
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:655 (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@100)
10.Static level top of casing:200 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
J10.Star tic water
is above casing,belowus "+" 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.)
Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: '7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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) Method of test:Air
20 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