GW1--06149_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD(GW-1) i For internal 1350.Only; f
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1.Weil Contractor Information:
Rick Crane •14:WATER 7ANES: I,i
Well Contractor Name FROM TO DESCRIPTION I
ft. ft. '
NC Welt Contractor Certification Number -15.OUTER CASING(for multi-cased wells)OR LINER(if ap Seattle) - " -
Crane Bros. Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL'
0 ft• 124 fL 6.25 in. SDR-21 PVC
Company Name
4.') „M.INNER CASING OR TURiNG(geothermal cirsed.icap). - - .
2.Well Coast:intion Permit:=: L FROM i TO I-DIAMETER THICKNESS I MATERIAL
List'all applicable,:r!!rarc,lrucfiwrpermlfs'(i:e.UK;UK;CunCounty,Sark,Ys:ria:ter,sly.) fir• ft., in.
3.Well Use(check well use): H. ft. hi.
Water Supply Well: tZ SCREEN" _
FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
UAarieultursl UA-,nnicipal/Prrblic .- ft. ft- in. 1.
❑Geothermal(TieatingiCooling Supply) t1Reaidential-Water Supply(single) ft: fL in, i "
❑lndustrial/Contmercial ❑Residential Water Supply(shared)
Dirrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft,bononite pun iged
' ❑Monitoring ORecoveey ft. ft. i
Injection Well:
ft. ft. •
❑Aquifer Recharge QGroundwatcr Rcmcdiation 19.SAND/GRAVEL PACK(if tl[tplicable) '
❑Aquifer Storage and Recovery- OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
-❑Aquifer Test ❑Stormwater Drainage ft. ft. [ .
U_:Xperimentul Technolowy ❑Subsidence Control ft. IL i
•❑Geothermal(Closed Loop) ❑Tr.icer -20:DRILLINGLOG(attach additional sheets if necessary)
QGeolliennal(Heating/Cooling Return) QOtiler(explain under 1121 Remarks) FROM To DESCRIPTION(color,hardness,soWroektype,grain sire,etc.)
0 fL 124 fL clay
4.Date lveil(s)Completed 09/06/2023 Well ID# 124 ft• 605 ft- granite
Sa.Well Location: ft._, ft.. •`-- :,d
Equity Trust Company ft. ft. '�`. - -•'L-s V t i,,)
Facility/Owner Name Facility ID#(if applicable) ft• ft.
Leatherman Gap Rd. Franklin, NC 28734 , ft. fr. JLI 2023
PhysicalAddress,City,aid Zip ft. I ft. Inforveraticn Prcr5tscN4 LR
Macon 6598032592 11.REMARK.S - Dvioino -
County Parcel Identification No,(PIN)
S. Latitude and longitude in degrcY=:/minutes/secontisor decimal deg_rec - ----
Olivet'field,one latilons-i;sufficient) . 22. ' cation:
35 16;554 N 83 23.269 w
j, 9/20/2023
6.Is(are)the well(s): QPermsnent or OTemporary lima of Certified Well Co Date
RysIgnlne.thisfirm•,thereby cer[ip that Ma w.^.11 ejwery(s/err.)r mtr+u:M.dui ar:rnr sure ws[ih,
7.Is this a repair to an existing well• LI°i e3 or MNo 1 Sa&CAC 02C.01oU or 15;1 WC4C 02C-0200 W 11 Comslsu;lion Simulants and that a copy
If this is a repair.flit out known well construction infor,nanon and explain the natm•e of the ojthis record has been provided to the well owner.
repair under#21 remarks section oran the bade of this form.
23.Site diagram or additional well details:
S.For GeoprnheJDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
conemiction only 1 GW-1 is needed lnflirst TOTAL NUMBER of wells 'See Over'in Remarks Box).You may also attach-additional pages ifnecessay.
drilled: 24..SUBMiTTAL INSTRUCTIONS
9.Total
multiple
ell depth below land surface:60 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multip wells list alldepths if dIerent(example-
3@200'and_aGi100)
24a. For All Wells: Original form to Division of Water Resources (DWR).
lU;Static era icrlevel below'lop of casing:?® (It.) Information Processing Unit.1617 MSC.Raleigh,NC 2769 9-1617
Il.Borehole diameter. 6.25 Om) 24b.For Tniecilon Wells:Copy to LIWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636 1
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i,e,auger,rotary,table,di tLet rush,eto,) county environmental health department of the county where installed
'FOR WATER SUPPLY WELLS ONLY: A ' 24d.For Water Wells producing over-100;000 GPD:Copy to•DWR.'CCPCUA
13a.Yield(gpm)`30 Metlwd.DftesL Air Permit Program,1611 MSC,Releigh,NC 27699-1611'
13b.Disinfection type:Sterilene Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6 22018