GW1--06453_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-cased wells)OR LINER(if ap licable)
Crane Bros. Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 82 ft. 6.25 I in. SDR 21 PVC
061522-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 ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) I.1Residential Water Supply(single) ft. ft. ink
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD 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 OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)• -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 82 it clay
4.Date Well(s)Completed: 09-25-2024 Well ID# 82 it 505 ft• granite
5a.Well Location: ft ft.
Alfredp Munafo ft. ; ft. •F.R ( ,. ; D :�,.
Facility/Owner Name Facility ID#(if applicable) ft. ft. NOV T 2021
1284 Hidden Hills Rd. Franklin, NC ft. ft.
Physical Address,City,and Zip ft. ft. r `,- ;,r
Macon 6573141178 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.Cer''cation:
N W e� , - 10/22/2024
•
6.Is(are)the well(s): OPermanent or ❑Temporary Signature f Certified Well Contractor Date
By signing this form,I hereby certf&that the well(s)was(were)constructed in accordance with __
7.Is this a repair to an existing well: ❑Yes or i!INo 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:
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: 505 (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@100')
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 op' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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)_5 Method of test:Air
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