GW1--03311_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD(t-TW-I) r For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATER ZONES
, FROM I TO I DESCRIPTION
Weil,,onin:ciur r'zmo (t. (t.
3073-A
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a We)
FROM TO DIAMETER THICKNESS MATERIAL
Crane Bros. Well Drilling :- I.... r- I . :.. I_ _ _ _
Company Name p :0 it IVii ft' I(i2b `n- 1SOR21 IPVC
010723-r" 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.) N. H. is.
1.We!rlsr lrhrgk well rise)• ft. ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. it io.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft n. in.
M r./11;n;al!Copsrn.rcial ^rc..sk.•t ntia!Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TU MAMMAL METHOD&AMOUNT
Non-Water Supply Well: 0 '� 20 ft benonite pampa
❑Monitoring ❑Recovery ft. ft.Injection Well:
• rl � I
CI Recharge ❑Groundwater Remediation i
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
0
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO Di
DESCRIPTION(color,bargains,►atdne wil/rock type,graingrainttu etc.)
ft. 68 ft• clay
4.Date Well(s)Completed: 3/21/2024 Wen ID# 68 ft 480 R• granite
•
5a.Well Location: II• II.
Rita Byrd ft n. : .. -. • " _
Facility/Owner Name Facility ID#(if applicable)
ft. ft. ti- '... r ..-
176R N. Jones Cr. Rd. Franklin, NC 28734 ft. ft. jUN v : 2024
Physical Address,City,and Zip It. ft.
Macon 6562715245 21.REMARKS .,....,:, ..
ilta<
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutesiseconds or decimal degrees: i i
(if well field,one 1at/long is sufficient) 22.Certification:
35 06.001 N 83 27.144 W //`�,'y/-�'��'`'�� ' 5/29/2024
c t-r.._-�the:..-n(_�. Ain _ -z..;�. r-:m„-_;;ram .. Si of Ce ified Well Contractor Date
-.1star .. well(s): __ _ - __• _._-.::r.:___.:
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 It No 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:
You tatty......::..,baca..4.;I a page:.. .4..• !weer co fo
8.For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same " "" u"vaa� rr "�` "` ::a. �` its race u tr"
constriction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total wail depth below land surface: 480 (R') Submit this GW-1 within 30 days of well completionper the following:
For multiple well.!1st all depths;rdur rent(example-301200•and 2i„41nn1 Y P 8multiple
Static water level below of casing 100 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10. ' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use top
11.Borehole diameter:6.25 (�) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well Kolar construction method: 7 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
I FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
3n Air Permit Program.1611 MSC.Raleigh.NC 27699-1 61 1
Litt.Yield(gpm) `�--. Method ul test: Air-
13b.Disinfection type: Sterilene Amount: