GW1--00335_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane -14:WATER ZONES '- -- ' - I -- .
Well Contractor Name FROM TO DESCRIPTION
fL ft.
3073-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER,(if ap liicable).
Crane Bros. Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 44 n- 6.25 1n' SDR-21 PVC
032522-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 t°'
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. iti.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. It. hi.
❑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 It. Benonite Pumped
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19."SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft. .
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.-DRILLING:LOG(attach additional sheets ifnecessaiy):• - .:
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soWrock type,grain size,etc.)
0 ft' 44 ft. Clay
4.Date Well(s)Completed: 10/09/20223 Well ID# 44 ft. 430 ft. granite
5a.Well Location: it ft. t k -F ^,t.®„ t �r 67
Paul Mossbarger ft. ft. : « v.,...` aV 4-i,....*
{j
Facility/Owner Name Facility ID#(if applicable) ft. ft. JAN 1 G 2024
Olive Hill Road, Franklin NC 28734 ft. ft. , _ <:� r- :r '
Physical Address,City,and Zip ft. ft. DWQ0 O a
Macon 6566927341 21.REMARKS -
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce fication: I
N W 1/3/2024
6.Is(are)the well(s): OPermanent or OTemporary Signature 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 ONo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If thts 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:430 (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"+"
11.Borehole diameter:6.25 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
13a.Yield(gpm) 15 Method of test:Air.
Program,1611 MSC,Raleigh,NC 27699-1611
_.
13b.Disinfection type: Sterilene Amount: . , i
. , i 'rrrrGW-1 North Carolina Department of Environmental Ckid)ity`- ion of Water Rees Revised 6-6-2018