GW1-2021-02104_Well Construction - GW1_20211008

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Constructon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-02104
Are you submitting a printed form?* r Yes
r No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Felton Jacobs Felton @Upfrontwells.corn
Is this a revision to the form you have previously submitted?
r Yes r No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
...................................................................................................
Certiticate# Cert Level First Name Last Name Company Name
2765 A FELTON JACOBS UPFRONT WELL COMPANY OF THE
CAROLINAS
2.Well Construction Permit#:
360879
List all applicable well construction permits(i.e.lVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* f Injection Well f Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
r Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

10/8/2021 2
(gallons per minute)"
5.Well Location
Facility/Owner Name
Dustin Harris Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Vance
Physical Address* Street Address
22 Water Front Drive
Address Line 2
City State/Province/Region
Henderson NC
Postal/ZZp Code Country
27537 US
Latitude* 36.4034350000 Longitude*-78.3887555000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and e)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GWA is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
504 surface?
Formultiple wells listall depths if different 26
(example-3 a200'and 2@100) in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
20 6
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
2 13a. Method of test:
If applicable Blow
13b. Disinfection type:* 13b.Amount:*
HTH 1 LB

14.WATER BEARING/FRACTURE ZONES
From To Description
295 300 1 GPM
in feet in feet
445 450 1 GPM
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
......... ......... ......... ......... ......... ......... .......
From To Diameter Thickness Material
1.00 25.00 6.00 .188 Galvanized
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 20.00 Holeplug Poured
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0.00 3.00 Top Soil
in feet in feet
3.00 20.00 Clay
in feet in feet
20.00 505.00 Granite
in feet in feet
21.Remarks
Used hardened steel drive shoe
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................

*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
OZenfl-
Signature of Certified Well Contractor
Submittal Date 10/8/2021