GW1--06451_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
ft. ft.
3073-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
Crane Bros. Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 67 ft. 6.25 in. SDR 21 PVC
Company Name
051324-1 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 O , DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. id
❑Geothermal(Heating/Cooling Supply) (]Residential Water Supply(single) ft. ft. id.
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT ._
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft. Benonite pumped
OMonitoring ❑Recovery ft. ft.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
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 FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. 67 ft• clay '
4.Date Well(s)Completed: 08-28-2024 Well ID# 67 ft• 1105 ft• granite
5a.Well Location: ft. ft.
�; ,; -'
Bill & Barbara Ware ft. ft. • '` " :I.1
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 'd0 V U ! Z024
Lot 15 Fulcher Vista ft. ft. Ir,`c;,
Physical Address,City,and Zip ft. ft. D'``• _:'<. i
Macon 6592967394 21.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.Cercation: j
35.11974 N 83.34922 W < < jl_ 10/22/2024
6.Is(are)the well(s): I1Permanent or ❑Temporary Signature f Certified Well Conti •
Date
By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with ._
7.Is this a repair to an existing well: ❑Yes or CJNo ISA 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: 1 105 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
150 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•'+"
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 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) Method of test:Air
6 Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018