GW1--06151_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.We11 Contractor Information:
Rick Crane 14.WATER ZONES '' ` . 1' I -
Well Contractor Name FROM TO DESCRIPTION P
ft. ft. I'
3073-A ft. ft. 1
NC Well Contractor Certification Number 'IS.OUTER CASING(for multi cased wells)OR LINER Of ap noble) : -•
Crane.Bros. Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 111 ft' 6.25 I"• SDR-21 PVC
Company Name ] -
011123- I6.INNER CASING OR TUBING(gentbermat-ctosed•loop) -
2.Well Construction Permit#: PROM 'ro DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(I.e.Ule,County,State,Variance,etc.) .fn. .it. in.
3.Well Use(cheek 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) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
'18.GROUT'' - • t # -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 20 fit• benonite pumped
❑Monitoring ❑Recovery ft. ft.
Injection Well:
it. ft.
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .,20:DRILLiNG LOG.(attoeh addidonalsheets if necessary) -
•❑Geothermal(Heating/Cooling Return) ❑Other(explain under821 Remarks) FROM TO DESCRIP710N(roloyhardness soWrocictype gtalaOise,et,
0 ft' 111 it. clay
4.Date Well(s)Completed:aY07121/2023 Well 1D# 11:1 ft' 925 it. granite
5a.Will Location: ft. ft.
James Sherbou rne ft. R. .7;-''rw 1 It P D
Facility/Owner Name Facility 1D#(if applicable)
ft. rt. 6 t.:�''.r 1.......r• V L$
47 Kool Lane, Otto, NC 28763 ft. ft. SEP 2 2 20?3
Physical Address,City,and Zip
ft.. ft..
Macon 6591707103 21.REMARKS . - - -- - jtttai N:1rtt C''fC-,n'i4.':'.4/Ulla
DW O
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one Iat/long is sufficient) 22.C ' cation:
35 04.558 83 23.226
N w et_02...,t___ 9/20/2023
6.Is(are)the well(s): CJPermanent or ❑Temporary Signa of Certified Well Contractor Date
Ety signing this form,I hereby certify that the wc//(s)war(mere)constructed in accordance with
7.Is this a repair town existing well: ❑Yes or eiNo I SA NCIC 02C:0/Oif or ISA'NCACO2C:0200 Well Constructiim Standards and that a copy
if this is a repatr,llll out known well construction oyor:nation and explain the nature of the of this record has been provided to the well owner,
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
S.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:925 (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths IIfd((erent(example-3(nn200'and 2@100' y p
10.Static water level below top of casing:,10.0 (ft.) 24a. For All Wells: Original form to Division:of Water Resources (DWR),
I Sta.level is above casing•are"+" lnfomration Processing Unit,1617 MSC,Raleigh,NC 27699-161-7
6.25 24b.For Injection Wells:Copy to.DWR,Underground injection Control'(TUC)
11.Borehole diameter: Om) Program,1636 MSC,Raleigh,NC 27699-1636 '
12.Well construction method: Rotary
(i.e.auger,rotary,estate,direct push;err.,) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
74d.For WaterWells producins over 100,00042 CA Copy to DWR,CGPCL
13a.Yield(gpm)20 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611'
13b.Disinfection type: Sterilene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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