GW1--04711_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES ,•
We11Con1mctorName FROM TO DESCRIPTION
ft. ft.
3073-A
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 TIBCKNESS MATERIAL
0 ft' 87 ft. 6.25 in' SDR-21 PVC
Company Name
081122-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) I!lResidential Water Supply(single) B. B. 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 R• benonite pumped
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANII/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) ❑Otter(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire etc.)
0 ft. 87 ft. Clay
4.Date Well(s)Completed: 05/22/2023 Well ID# 87 ft• 1005 ft. granite
5a.Well Location: ft. ft. ' '' l�^a} ,,
Michael Ledford/Bob Ray ft. ft. N a.--t ,C s \�t D
Facility/Owner Name FacilitylD#(ifapplicable) ft. ft.
5274 Georgia Rd. Franklin, NC 28734 ft. ft. JUL 2 4 2023
Physical Address,City,and Zip ft. ft. Int'(NRY'+el,„tail Prnc.30.44 Da
Macon 6582910174 21.REMARKS -
- aiiii0;8 oc-
County Parcel Identification No.(PIN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 05.949 N 083 22.342 w .; r 7/20/2023
6.Is(are)the well(s): lPermanent or ❑Temporary Signal of Certified Well Contractor i 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 8No 1 SA 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 CW-I 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: 1005 (ft.)
For multiple wells list all depths ifdi(terent(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:50 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
JJw alai 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.)
Rotate 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) 1 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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