GW1--00325_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATERZONES = " ' - - "
Well Contractor Name FROM TO DESCRIPTION
3073-A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap licable) -
Crane Bros. Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 rt. 143 It. 6.25 I in. SDR-21 PVC
Company Name 16.INNER CASING TUBING'(keofhermel closed-loop)' = =
2.Well Construction Permit#: 2023-24499-9-12687 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.
17.SCREEN
Water Supply Well: - -- -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) L'JResidential Water Supply(single) g• ft. in,
❑industrial/Commercial ❑Residential Water Supply(shared) i8.GROUT -. - `- -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - - • 0 n' 20 ft. Benonite Pumped _
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 39.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) OTracer -20.DRILLING LOG(attach•additional sheets if necessary). '- •" ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness salllractc type,grain size,etc.)0
0 ft' 143 it• Clay
4.Date Well(s) 10/13/2023 IL Completed: Well m# 143 780 It- granite _,,T_,
Sa.Well Location: ft. ft. 1+� LP 0 ' i"� l
Bob Showalter ft. ft. 1A!V 1 ei 2021
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1330 Hi Top Mtn Rd..Whittier, NC 28789 ft. ft. irif,-;;t:atic:t Prc 5€44: URI
Z t.y v." ,
Physical Address,City,and Zip ft. ft.
�v
Jackson 7612-37-8289 21.REDIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ' cation:
N W ,CA, 1/3/2024
6.Is(are)the well(s): nPermanent or ❑Temporary _ , Si of Certified Well Contractor Date
By signing this form,Thereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or eiNo 15A NCAC 02C.0100 or 15A 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-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: 780 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If different(example-3®200'and 2®100) 1
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 00
Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: rota1-'7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departiment 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) 15 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
, '
13b.Disinfection type: Sterilene Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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