GW1--06449_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane :14.WATER ZONES . .
Well Contractor Name FROM TO DESCRIPTION
3073-A ft. ft.
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' 106 ft. 6.25 ; in' SDR 21 PVC
Company Name
060223-P 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. • ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. ins
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. ft. 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
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
1 19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery . ❑Salinity Barrier FROM TO MATERIAL • EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. .
•
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 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,grain size,etc.)
0 ft. 106 ft• clay
4.Date Well(s)Completed: 06-17-2024 Well ID# 106 ft• 580 ft. granite
5a.Well Location: ft. ft.
Evelyn Baker ft. ft. 4 E;a..4 ,'....- °.:%' :;;
Facility/Owner Name Facility ID#(if applicable) ft. ft. NO `l 1 202;
181 Langston Howell Dr. Franklin, NC ft. ; ft. Vl/V 2
Physical Address,City,and Zip ft. ft. it,..v. •, 'r - -,,_,`$,,M
ft
Macon 6556415681
2L'REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer' cation:
N W c C 10/22/2024
6.Is(are)the well(s): CJPermanent or ❑Temporary Signatur 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 InNo 1SA NCAC 02C.0100 or 1SA 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 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 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
9.Total well depth below land surface: 580 (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@I00') i
10.Static water level below top of casing: 1 00 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use'•+^ Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
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
13a.Yield(gpm) 15 Method of test:Air
Permit Program,161.1 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
1
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018