GW1--00331_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ;
1.Well Contractor Information:
Rick Crane 14WATERZONES.
VJcll Contractor Name FROM TO DESCRIPTION
3073-A ft. ft. I
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for wells)OR LINER(if ap licable)
Crane Bros. Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 140 ft• 6.25 ! in* SDR-21 PVC
060523-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. is
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17."SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft. in.
OGeothermal(Heating/Cooling Supply) L!Residential Water Supply(single) ft ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. Benonite Pumped
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/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. 1
OGeothermal(Closed Loop) OTracer ,20.-DRILLING LOG(attach additional sheets if necessary) _ . -
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
0 ft 140 ft. Clay I
4.Date Wetl(s)Completed: 10/27/2023 Well ID# 140 ft• 305 R• granite i.-- (-.,. .t t f cr.-.a,,,
5a.Well Location: ft ft. r'Q r m k..,r i! ' v r.. 9
Brian Kelly ft ft ila.v i '2, 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Hwy28N.Franklin,NC2834 ft. ft to Grit :9E:1 tr.Ms4):31-5+1 a
Physical Address,City,and Zip ft. ft.
Macon 6586669454 21.REAfARKS'.
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. ertitication:
35 12.599 N 83 23.377 W � 1/3/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor 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 elNo 1SA 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-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: 305 (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)
100 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"+"
11.Borehole diameter: 6.25 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(DX)
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
1'
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount: i
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018