GW1--00332_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: '
1.Well Contractor Information:
Rick Crane 14:WATER ZONES , . -
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3073-A
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 ft. 84 ft- 6.25 ; in. SDR-21 PVC
• Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) _
2.Well Construction Permit#: 070923-P 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): it. ft. is
-17.SCREEN.-. •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[Agricultural OMunicipal/Public ft. ft. hi.
OGeothermal(Heating/Cooling Supply) I`lResidential Water Supply(single) ft. ' ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) . 18.GROUT" . " . _• , - "
❑Irrigation ❑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.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 720.DRILLING,LOG(attach additional sheets if necessary)''-'. ` :__ Y.
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sad/rock type grain size,etc.)
0 s. 84 ft. Clay .
4.Date Well(s)Completed: 11/20/2023 Wen ID# 84 ft. 405 ft. granite
ft. ft.
Sa.Well Location: ft. ft. `�f t.L.r.vV R LP
Camille A. Barton-Green5-M` a
Facility/Owner Name Facility ID#(if applicable) ft, ft. I AN 1 2024
220 McCoy Hill Rd. Franklin,NC2834 ft. ft.
Physical Address,City,and Zipft ft, mf: rr�n`z , '�7, g
Y rrr O/�O3
Macon 6578326737 21.REMARKS;
County Parcel Identification No.(PIN) I5b.Latitude and longitude in degrees/minutes/seconds or-decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 16.197 N 83 26.710 W 0 - 1/3/2024
6.Is(are)the well(s): l lPermanent or ❑Temporary SiteZ,re of Certified Well Cuntraator Date
By signing this form,I hereby certifythat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!INo 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-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:405 (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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 100 (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 (in.)
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 10 Method of test:Air
13b.Disinfection type: Sterilene Amount: .
Form 6W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018