GW1--00337_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
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1.Well Contractor Information:
Rick Crane 14.WATER ZONES . _ . -- -
Well Contractor Name FROM , TO DESCRIPTION
3073-A ft. ft. I .
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' 24 ft- 6.25 i SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -. .- -
2.Well Construction Permit#: 7418-46-2977 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.SCWater Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) I•JResidential Water Supply(single) rL n• 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 ORecovery 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 ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary): - - .- - .
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 24 ft. Clay
4.Date Well(s) 09/22/2023
Well m# 24 1005 7--,Completed: ft• ft• granite r--: . --_-�: 7"'""7"'""Sa.Well Location: ft. ft. "6 ,(;.....4..:.:_ i'its C.
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Rick Greer ft. ft. .1/4IN i G 2074
Facility/Owner Name Facility ID#(if applicable) ft. ft. I
Osage Lane Scaly Mtn, NC 28734 ft. ft. l�""'"```° ` `'s's��
�,t?vrJ7 �
Physical Address,City,and Zip ft. ft.
Macon .21.REMARKS -. - - . -
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
N W ,,_ 1/3/2024
6.Is(are)the well(s): t!Permanent or ❑Temporary Signat 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 ONo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infarmation 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 GeoprobelDPT 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
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9.Total well depth below land surface: 1005 (ft.)
For multiple wells list all depths if different(example-3®200'and 2Q100) Submit this GW-1 within 30 day!of well completion per the following:
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 Om) 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).0 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018