GW1--01939_Well Construction - GW1_20240325

,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER'EONES 1 -,
Well Contractor Name MOM TO DESCRIPTION
pp ft. I ft.
3073-A
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING(forinuiti-casciI.Melts)OR LINER(if up livable)
Crane Bros Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 it. 104 H• `6.25 ' in-SDR-21 PVC
Company Name
2.Well Construction Permit#:O" ���7 _p 16.I:I'iER.CASii:G OR TUBING(geothermal doses'-loop)
FROM •TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(Le.UIC.County.State.Variance,etc.) n. . m its.
3.Well Use(check well use): ft. ft. in..
Water Su 1• Well: �17.SCREEN: ' - ' .
pp FROM TO DIAMETER I SLOT SIZE THICKNESS - MATERIAL •
❑Agricultural ❑Municipal/Public ft, n. in. l
UGeothermal(Heating/Cooling Supply) UResidential Water Supply(single) fL n, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) , 18.GROUT _ -_ _ .- ' • _
flirrigation flWells>100,000 GPI) FROM TO MATERIAL i EMPLACEMENT METHOD S•AMOUNT
Non-Water Supply'Well: 0 ft. 20 rt. benonite (pumped t
❑Monitorittg ❑Reunvery ft. ft. i i
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.S.4NDiGRAVEL PACK(If applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM i• TO • MATERIAL EMPLACEMENT METHOD
DAquifer Test OStormwater Drainage ft. i ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) _ ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sciUrock type grain size etc.)
0 ft' 104 ft' clay
4.Date Well(s)Completed: 11103/202 Well ID# 104 ft• 705 ft. granite
Sa.Well Location: ft. ft.
Eugene DeBullet __ ___ ft. ft. -
Facility/Owner Name -WJ Facility 1D,:(if applicable)- ft. fit. t: t,-.&N�,;i 1..". t_ _,,1
1197 Corundum Hill Rd, Franklin, NC 28734 ft. ft. MAR 2 ti 2024
Physical Address,City,and Zip R. ft.
5 21.REMARKS - -Ifl Cf, 41:4Tn �!'^^.:564:°,u::1 tr.X
Macon 71137851 s�4 - �,
Ds+''Cuw
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Ia€/long is sufficient) 22. 'Emotion:
N W 3/13/2024
6.Is(are)the well(s): LIPermanent .or OTemporary Si atn a (; ,�ofCertitied Well Contractor Date
By sinning 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 IhLY is a repair,fill oat 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 OW-I 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:705 (fit.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2(a)i00)
pp 24a. For All Wells: Original form to Division of Watcr Resources (DWR),
10.Static water level below top of casing: 80 (ft') Information Processing Unit,160 MSC,-Raleigh,NC 27699-1617
If water level is above casing,use"•1 I
11.Borehole diameter 6'25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary ,i '
24e 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,
Yield(gpm) 12 Method of test:Air NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018.