GW1-2022-00160_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
4328-B g ft. 15 & I I I
ft. ft. j '
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER it a licable
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
WM0401419 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 rt. 55 ft. 1 m. .25 PVC
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural (]Municipal/Public 5 ft. 15 ft. 1 in.
.010 .25 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial n Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
a x Monitoring__ _[Recovery___ _ ft. _ ft.
r -
Injection Well:
ft. rt.
Aquifer Recharge rlGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage 3 & 15 ft. #2 Sand Pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets ifnecessa
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:12-12-22 Well ID#TW 1,2,3,4,5 ft. ft. .:~�� 4 M.5a.Well Location: ft. ft. P
Precision Printing & Sign, ft. ft. DEC
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1302 Blowing Rock Road, Boone, 28607 Piz
rill
mot-.•a
Physical Address,City,and Zip ft. ft.
Watug a 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36.202770 N 81.664706 W
� 12-14-22
6.Is(are)the well(s)oPermanent or xOTemporary Signat of ed 19611 C&fitractor 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: [3Yes or BNo 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:Five (5) SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: 15 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d8erent(example-3@200'and 2 a 100') construction to the following:
23
10.Static water level below top of casing:9. (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:2.25 (in.) 24b. For Iniection Wells: In add I ition 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 SunDly& Iniection 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. !!
i
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016