GW1--04011_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant 14.WATER ZONES ilr
Well Contractor Name FROM TO _ DESCRIPTION
4328-B 20 IL 25 fL
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if apelicable)
JGDrilling LLC FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. in.
Company Name
70003211 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROMTO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft• 20 ft• 1.25 in. .250 Steel
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESSMATERIAL
Agricultural EjMunicipal/Public 20 ft. 25 ft. 75 in. .006 .125 Stainless
ID Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
In Industrial/Commercial 10 Residential Water Supply(shared) 18.GROUT
11 IrrigationFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. None
X°Monitoring 0 Recovery ft. ft.
Injection Well: ft. ft.
O Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test DStormwater Drainage ft. ft. None
0 Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size.etc.)
0Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft.
6 26-24 GW 2 ft. ft. •-
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft. 4.'N.:`e�",• �, .
IOS-PVB Holdings/Jeff Josephs ft. ft. JUL J 8 20Z4
Facility/Owner Name Facility ID#(if applicable) ft. ft. r, l-.3",;:-
- n
3510 Robinson Circle, Charlotte, 28206 ft. ft. 1f4c�1A-iww
Physical Address,City,and Zip ft. ft.
Mecklenburg 08506130 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one latAong is sufficient) 22.Certification:
35.257343 N 80.810724 W
' 6-27-24
6.Is(are)the well(s)IJPermanent or DTemporary Signature of ni ell utra o� 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: DYes or 3No 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: 25 (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@100') construction to the following:
10.Static water level below top of casing: 20.00 (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 Iniection 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 SuoDly&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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016