GW1--03322_Well Construction - GW1_20240603

WELL LL CONSTRUCTION RECORD i t1 W-11 For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATERZONES
FROM I TO I nrsent►rioN •
i1 eu 1.11iiiracior Name
ft. ft.
3073-A
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells)OR LINER(if a bk)
FROM TO DIAMETER THICKNESS MATERIAL
Crane Bros. Well Drilling _. I. _ :_ I . _.. ._ I ___. orbit)
Company Nara U it34 '- ib.LJ r ISUKL1 f F'VC
2023-24633-9-13740 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. R. in.
1,IWO IN.?IcherL_verlf!me)r ft. ft. in.
• i i i i
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply) PJResidential Water Supply(single) ft. ft. in.
nIrtA:W.iriallrnr r•:.-Tfia• EIResidcntia!Water Supply(aflame.) • lg.GROUT
❑irrigation ❑Wells>100,000 GPD FROM r0 MAI'Ett1AL EMPLACEMENT ME 1'HOD AMOUNT
Non-Water Supply Well: 0 ft. 20 benonite pumpe
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge DGroundwater Remediaticm 1 1 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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,train size,etc.)
0 ft' 84 ft. clay
4.Date Well(s)Completed: 4/29/2024 Well ID# 84 ft• 1055 IL granite
ii. ' fi. '
5a.Well Location:
Fitz Fitzgerald -�it ,t L_
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Bear Ridge Road S Jlua NC 2879 ft. ft. J-UN U c 2024
Physical Address,City,and Zip
Jackson 7587*71*9581 21.REMARKS L r ft. ft. Ir.`. ::. _:`.1 h'""6+[sac't� JylE
i ,,4.1
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one ladlong is sufficient) 22.Certification:
34 2 5234 N 83 0 6078 W
Q,,,1t-- 5/29/2024
e)the -or-♦. n, sent ,-,•.•_ r.._,.._. SiltnatgAzt
Certified NMI Contractor Date
,_(
By signing this form,l 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 15,4 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:
8.For(.eoprobe/DPT or Closed-Loop Geothermal Wells having the same You"may us,:late buck of this r.e, topro.i:c additional rt_l construction info
construction,only 1 GW-1 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 well depth below land surface: 1055 (ft.)
For multiple tills liar e!!depths if a...(example-3/a inn and�r r i Submit this GW-1 within 30 days of well completion per the following:
depthsdi.._ e. ._M_'.
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 (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
1 I nr 1 nt Air Permit Program.1611 MSC.Raleigh.NC 27699-1 61 1
13a.Yield(gprn) r°' - • "1= !Method of lest:
13b.Disinfection type: Sterilene Amount:
sin::!a,:.n�..-, ., i
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