GW1-2022-03425_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
8.11 ft 13
4328-B ft.
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi­cased wells 0 LINER if a licable
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 9 ft 1.5 in. .25" ISteel
WM01 00508 16.INNER CASING OR TUBING ebthermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc.) ft ft in.
3.Well Use(check well use): fa ft. in.
Water Supply Well 17.SCREEN
• FROM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
_ Agricultural ®Municipal/Public 9 fl- 13 fl- •75 in•' .006 •25" iss
_ Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT i ;z' -
irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fa ft.
x Monitoring QRecovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if o licable
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 neceskAo)
FROM TO DESCRIPTION color,hardness,soil/rock rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed:3-14-22 Well ID#GW 2 ft. ft.
9 �, Ft1
Sa.Well Location: ft ft.
Tom Mosey Properties & ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. MAR -
1989 Old Rosman Hwy, Brevard, 28712 ft. ft.
Physical Address,City,and Zip ft ft a _�zt' �. f w v:�i INA
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:
35.143753 N 82.812771 W
9:!nld� 9!!�
3-14-22
6.Is(are)the well(s)13Permanent or x Temporary Si t art' d 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: E)Yes or XJ 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:
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:One SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 13 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 tt/00') construction to the following:
10.Static water level below to of casing:8.1 1
p g: (ft.) 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: 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
I
13s.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