GW1-2022-03424_Well Construction - GW1_20220318

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4328-B 9.30 ft 17 ft
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for miilti�ased wells ORLLINER%if'a licable .«
JG Drilling,LLC FROM TO DIAMETER TxICKNESS MATERIAL
Company Name
0 ft- 13 ft• 1.5 in. .25" ISteel
WM 01 00508 16.INNER CASING OR TUBING eothermal closed400 tkl
2.Well Construction Permit#: FROM TO DIAMETER I 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 13Municipal/Public 13 ft- 17 ft .75 in. .006 .25" SS
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft in.
Industrial/Commercial EiResidential Water Supply(shared) 18:GROUT I=
Irl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT•�
Non-Water Supply Well: ft• ft.
x Monitoring ®Recovery ft ft.
Injection-Well: -
-- - ft ft
_ Aquifer Recharge [3Groundwater Remediation - -
19.SAND/GRAVEL PACK if applicable '-
Aquifer Storage and Recovery rlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C]Stormwater Drainage ft ft
Experimental Technology 0Subsidence Control ft ft.
Geothermal(Closed Loop) ®Tracer 20:.DRILLING LOG attacfi'additionalsheets'if;necessa "` v
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiVreek rein size,etc.
ft ft
4.Date well(s)Completed:3-14-22 Well IN GW-3' GW-4 ft. ftIlk
Sa.Well Location:
ft ft.
Tom Mosey Properties ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ftMr• ?tz bw�h
1989 Old Rosman Hwy, Brevard, 28712 ft ft
Physical Address,City,and Zip ft ft
Transylvania 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.Certification:
35.143891 N 82.813322 W
9te�f� 3-14-22
6.Is(are)the well(s)13Permanent or 19Temporary Sign re oTC-ertifiedeWelKontractor 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: ®Yes or Jallo 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 o>ner.
repair under 911 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 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:TWO SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 17 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ different(example-3 a 200'and 2@l00') construction to the following:
10.Static water level below top of casing:9.30, 13.60
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise•'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (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&Infection 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016