GW1--01938_Well Construction - GW1_20240325

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I.
1.Well Contractor Information:
Rick Crane 14.WATER ZONES i .
FROM TO DESCRIPTION
Well Contractor Name
ft rt.
3073-A ft. . ft
NC Well Contractor Certification Number •
15.OUTER CASING(fur muHi-cased wells)OR LINER(If tip livable)
Crane Bros Well Drilling, Inc. FROM TO DIAMETER TIHCICNESS MATERIAL
0 ft `91 n 6.25 in' SDR-21 - PVC
Company Name r�q ~16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit$�' O� LLJ�p FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LUC.County.State,Variance,etc.) ft. rt. in.
3.Well Use(check well use): ft. ft in.
tt I Well 17.SCREEN
Water S
pp FROM TO DIAMETER I SLOT SIZE i THICKNESS I MATERIAL
❑Agricultural CMunicipal/Public ft. ft, in. !
IuGeolhermal(Heating/Cooling Supply) UResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
flirrigation f lWell>100,000 GPD FROM I-TO _ 1 MATERIAL _ F.MPI.ACEMENTMETDODA AMOUNT
Non-Water Supply Well: 0 ft 20 et' benonite pumped ` i
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
GAquifer Test CStotrnwater Drainage ft. ft. • -
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) DTracer 20.-DRILLING LOG(attach additional sheets if necessary): - i
FROM TO DESCRIPTION(color,hardasss,sell/rack type,grain zr,cut.) •
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 4 ft. �e, ft. clay
4.Date Well(s)Completed: 1 0/31/23 Well ID# 91 ft. 955 it• granite
ft. ft.
5a.Well i.ocation:
Grace Chapel DBA Sky Valley ft ft. r:TM R-';._ 7---:` _ I
Facility/Owner Name -— -� Facility ID#(if applicable) ft. ft '4..-.i, 'k�..>, (I 9^—,''��
Off Dillard Road Scaly Mt, NC ft. ft. MAR 2 2C2n
ft. ft. '
Physical Address,City,and Zip nQ A C�+q !n'<" YJ''`i3 �
Macon 7408147563 21.REMARKS - t;.s"y; O? '. . .
G v+E.ul u J(3
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification: •
N _ tier •Ak .e . (°/lam-t�s -- 3/13/2024
6.Is(are)the well(s): LlPermanent or ❑Temporary Sign tore of Certified Well ContractorDate
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 NNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
•ff this is a repair,fill us!knon,i eell cut::truelion!afrrrnation and explain the:iature Of ald 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessity.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 955 (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@a 100) r
Ill.Static water level of casing: �� (fL) 24a. For Ail Wells: Original 'form to Division of Water Resources (DWR),
Ill.St level is above ecl below,use top Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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
24e,For Water Supply and Openi.nop Geothermal Return Wells:Cony 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) 15 Method of test:Air
13b.Disinfection type: Amount: '
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018