GW1-2021-07636_Well Construction - GW1_20211201

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1,
1.Well Contractor Information:
Jeffrey Grant 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4328-B 13Aft- 20 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER'ifa'"Gcsble
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 10 ft. 1 i° .25" PVC
VVIVI0100502 16.INNER CASING OR TUBING eothermalAosed-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. in.
Water Supply 1 17.SCREEN
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL..,.
_ Agricultural ®Municipal/Public 10 ft- 20 ft. 1 in. ! .010 25n PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) ;IS::GROUT,`' ' l.; ,; lx ..:
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
x Monitoring Recovery ft. ft.
Injection Well:
- ft. _ ft. -
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OJ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage 8 & 20 ft. Sand Pour 12 Pounds
Experimental Technology E1 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional sheets if
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM ft. TO
To DESCRIPTION color,hardness,soil/mck rain size,etc.
4.Date Well(s)Completed:11-22-2 1 well ID#B-4, B-5, B-6 ft. ft.
5a.Well Location: ft. ft.
Biltmore Church ft fL 't^k6t
Facility/Owner Name Facility ID#(if applicable) ft. It.
103 Educationb Drive, Flat Rock, 28731 ft. ft. 2
Physical Address,City,and Zip ft It. l tsJ r r
Henderson 9587690356 21.REMARKSart .-.
t t Div ri%(.1:SSING U
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certif ation:
35.293647 N 82.399442 W1-7
11-23-21
6.Is(are)the well(s)oPermanent or rXITemporary Signatur&6fCertified W I Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: oYes or XI No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:Three SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For AII'Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if dierent(example.3@200'and 2@I00') construction to the following:
13.49,13.44,14.36
10.Static water level below to of casin ft.
p g: ( ) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Direct Push above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& Injecti In Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016