GW1--07770_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD (GW-1)• . : For Internal Use Only.:. .. . •: - .
.1.Well Contractor-Informationh • .
- Jeffrey Grant
y :- la:.wATER zoNEs ..
Well Contractor Name. .. . FROM TO DESCRIPTION .
4328-B :. • 18. -::ft.. 22• : . ft..• =•. I
ft ft.
NC Well Contractor Certification Number •
15.OUTER CASING(for multi cased Wells)GR LINER(if ap Duthie) '
' JG DrillingLLC • '
Company Name .
FROM TO DIAMETER' THICKNESS • � 'MATERIAL
16:INNER CASING OR TUBING(geot i mal closed-loop)•. '
• r 1IV - • .. -, 700031.71 •
2.Well.Construction Permit#: � FROM • TO: DIAMETER- : THICKNESS MATERIAL
List all applicable well constructionpermits i.e.UIC,•County;State Variance,etc. ft ' .. ft in:.
PP r ty. .0 . 18 . 1:5;__' .- . .25 Steel • :: .
.3:Well.Use(check well use): • . . . • . . :ft.- : ft: ' ., in- •
Water:SdPP1Y.Well: • • : .. MATERIAL
• 1 06
11 Agricultural . : . .. DMuniapal/Publie -. $FROM fREE 22 ft 'DIAMETER
in. SLO
T SIZE THICKNESS
.:7 ,25 SS . . .
Geothermal:(Heating/Cooling Supply) Residential Water.Supply(single) .; , ..ft. :ft ., • in, - .
- Ijy Jndustrial/Commercial •• Residential Water:Supply(shared) 18.GROUT
_i I Irrigation .: . .. O
• FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
: Non-Water Supply Well:.: . ' . , • '• . t .' : : .: '. . ' .
• ' • f f t
. . • • MiMonitoring. • • .. . - ' • . • • Recovery: •• ' .. : ' ' ' : . : - •'ft. .: : ft. • • - • _•- .: :
Injection Well: . .
•
!U Aquifer Recharge; • DGroundwater Remediation•
• ' •' 19.SAND/GRAVEL PACK(if applicabley '
''aIAquifer.Storage arid Recovery- • • ' : DSaiinityBarrier, . :. -• : . FROM . •' .TO .. . ' MATERIAL' EMPLACEMENT METHOD' ..• .. : '
: Am Aquifer Test: , . . •DStormwater Drainage . . • ft .: : ' .. 'ft •
: U Experimental Technology : • ` •Ijj]Subsidence Control' ••-. .• .. .ft.•. • ft . .. . '' • • .• .. • •. -• '
• II Geothermal(Closed Loop) . .-•OTracer . • : : • - 20.DRILLING LOG(attach additional sheets-if necessary) • .
'FROM . . ' TO• • ' DESCRIPTION(color,hardness;soi/rock type,grain size;etc.) ,- '
' _I Geothermal.(Heating/Cooling Return)• n Other.(explain under#21 Remarks)• • ft ft:
'11_-3-23 : • GW-1,2.3,4. _ : 'ft ft •• • 4.Date WeR(s)Completed: • • •Well ID# • .. • :
• ft •
•- ' Sa:Well Location: 1
''','"•.'':.-..-"Heaven Sent Catering/S. . ft ft
Q ,i' i.
L i 'j.
Facility/Owner;Name : . '. ' Facility ID#(if applicable) ft .. : ft. .. .. D`C'1), I .2 n?1 .: : .
. • •. 2300 Beatties Ford.Road; Charlotte,'28216: • :-.. ft.. • : :•_: ft : - : : .
.• ft:. :�,, -. . ,r via .
Physical Address,City,and-Zip. • ft;' .. : . . : r�•VC...•,.,:3i a . .
Mecklenburg . 07502106 : 21:REMARK:S
County :' Parcel Identification No:(PIN) -
. • . Temporary well. �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;". • •. • ; •
•' . (if well field,one tat/long is sufficient) • .. .'• ; ; • .: .' .22.Certification: '• : : • - :
: • 35.265268. :- • e 80.853855.: • -- .. : • • •W
11
•
6.Is(are)the well(s)CJ Permanent : or. la temporary : . .
Signs e o07—
ntractor Date-3
-. . :
- - . . 7.Is this a repair to an existing well: .QYes' or M No • - construction Standards By signing this form,7,hereby cert�that the well(s)�was.(were).constructed in'6ccordpnce
with 15A NCAC 02C,0100 or 13A•NCAG 02C:0200 Well Cons lion S ndards 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 proUided-to the well owner. ' •-
repair under#21 remarks section or an 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:Four • •_ . SUBMITTAL INSTRUCTIONS ,
9,Total well depth below land surface: 22 ' - (ft.), , 24a. For All Wells: Submit this form within 30 days of completion of well:. •
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
•1.8.70
10:Static water level below top of casing . . . (ft.) Division of Water Resources,Information:Processing Unit,
- If water level is above casing-use"+" 1617 Mail,Service Center,Raleigh,NC 27699-1617-•1.5" , ;-
11.Borehole diameter: (in:); 24b.For Injection"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 ServiceCenter,'Raleigh,NC 27699-1036 •
' •
•13a:Yield(Om) . • ' i - Method of test: 24e.-For Water Simply&Injection Wells: In addition to sending the form to
the address(es) above, also subhiit 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