GW1--06150_Well Construction - GW1_20230922

t1ELL•CONSTRUCTION RECORD(GW-1) I For Internal Use Only;
I.Well Contractor Information: 1 1
Rick Crane _14.WATER ZONES_ - - - - f - _
Well Contractor Name FROM TO DESCRIPTION I I
3.073=A I" 4t. 1. ft. I`!
NC Well Contractor Certifieatioe.Number Inc. IS.OUTER CASING(for multi-i;nsed wells)OR-LINER(Won licnble)
Crane Bros. Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 60 ft• 6.25 in- SDR72;1 PVC
Company Name .16.INNER CASING OR TUBING(geothermal cL -
tsed-loop) - -
,.23 Wei CCPwtructien Permit":071521-p-r FROM .J TO R DIAMETER 1 THICKNESS R MATERIAL
List all applicable nail cJas-truclian perm/ls•(i.e.UIC,County,S/ale,Variance,'ale.) .l It." -'.ft. in- I,
'3.Well Use(check-well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
❑Agiieiikui l ❑nth ictlisl/Puililic I ft. ft. In.
lI '
❑Geothermal(Heating/Cooling Supply). OResidential Water Supply(single) 1 fr. ft. In.
R
❑industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n ft. 20 ft• benonite pumped
❑Monitorinu • ❑Recovo v_ ft. ft.
Injection Well: 1 I
it. ft.
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL"PACK(If ajiplicable)
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑AquiferTest ❑StormwsterDrainage' it. ft.
❑Experimentai Technology °Subsidence Control ft. l ft.
❑Cieothennai(Closed Loop) ❑Tracer ."2U;DRILLING LOG(attachLoa(intack additionalshects If necessary) . -. -
l7Geothetmal(Heating/Cooling Return) °Other(explain under tf21 Remarks) FROM TO DESCRIPTION(color,hardness sowrock rive,grain she,etc.)
0 ft. 60 D• clay ;'
4.Date I.eli(s)Completed:08/21/2023 Well1il# 160 ft• 405 ft• granite j
5i.'Well Locatina: .1 ft. .1 ft..
�-- .„ 4,r.,
John Hoechst ft. ft. pi�,, `_y ;
s t' ' t.r�i.-.i.
Facility/Owner Name Facility 1D#(if applicable) ft' ft. 1 ;
Rocky Knob, Scaly Mtn. NC ft. ft. . ` SEP 2 2 20 3
Physical'Address.City,and Zip f I ft I. .
Macon 74186553/4 21.REMARK.S . •.lnsv, alri-C��II 1�y4��r�.:1.1�v�vw... Ur
L.JY�Qt•J OG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well-&:ld.onclat/lo~;g-is sufficient) •2241 6 cation:
35 00.292 N 83 17.128 w [ 9/20/2023
6.Is(arc)the well(s): °Permanent or OTemporary Signa of Certified Well Contractor Date
I
Rv.cinnhm fhb farm,I f arshy eartifi that the wall(a)meg(uarrj rnnctr eted in area men.with
7.Is title repair cO an existing well: Urea• or ilNo t;.1 NC:tC'02C'.ai011or I,st Ar4C"02C.020a Well Co,ylirr cam.4ue,dnrtis and that a copy
If thiss is a repair,fill out known well construction information and explain the nature of die of this record has been provided to thewe l 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
tirilied: 2.4.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:405 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdyferent(example-3(N200'and 2®100)
I
50 24a. For All Wells: Original form to Division of Water Resources (DWR).
III Static:•,atcr herd below-top of cushurz (ft.) Information Processing Unit.1617 MSC.Raleigh,NC 27699-1617
).:Ter level is.ar'*a casing.use"r„
h
(j 9 24b.For Infection Wells:Copy to DWR,Underground injection Control(IUC)
11.Borehole diameter (in.) I
� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary;cnble,.direct push,etc,) county.eniironmental health department of the county.where installed
FOR WATER SUPPLY WELLS ONLY: i
24d.For Water Wells producing over 100;000 GPD:Copy to DWR;CCPCLI A
Permit-Program,1611 MSC,Raleigh,NC 27699-16 11
13a.Yield(gpm) 1-5 Method'of test:.Air I
Lib.Disinfection type:Sterilene Amount: .
Form GW-I North Carolina Department of Environmental Quality--Division of Water Resources Revised.6-6-2018