GW1--06455_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Crane 14.WATERZONES .
Well Contractor Name FROM ft. TO ft.
DESCRIPTION
3073-A ft. ft. 1
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. 84 it 6.25 , 1°• SDR 21 PVC
041822-PA 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. I 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) nResidential Water Supply(single) ft ft inl i
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Oh-ligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 it 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 ❑Storrnwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft. j
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 84 ft clay
4.Date Well(s)Completed: 07-12-2024 Well ID# 84 ft 555 ft granite
5a.Well Location: ft. ft.
Kyle Price ft. ft. 1:.-,_ .- --,Ti.''''',.. 7 f. ft. ti%,a, 4,, t . d ey
it.. lFacilitY/Owner Name FacilityID#(if applicable)
223 Creek Road, Franklin, NC ft ft NO k? , 2024
Physical Address,City,and Zip ft. ft. j'
Macon 6580341354 21.REMARKS .. -,4'-� I I,I;
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.Ce ation:
N w � -- 10/22/2024
6.Is(are)the well(s): CIPermanent or ❑Temporary Signat Certified Well Contractor Date
By signing this form,I hereby cert,that the well(s)was(were)constructed in accordance with -
7.Is this a repair to an existing well: ❑Yes or dNo 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
555 I,
9.Total well depth below land surface: (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)
1 00 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: Copyl'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) 1 0 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