GW1-2021-07637_Well Construction - GW1_20211201

Print Form
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 7.19 ft. 14 ft.
fL ft.
NC Well Contractor Certification Number
15.OUTER CASING for mold-cased wells OR LINER'if a"licable w-.-
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft g ft. 1in. 1 .25" IPVC
Company Name
WIf A01 0oGJo2 16.1NNER CASING OR TUBING eotherinal closed=loo
2.Well Construction Permit#: IVI FROM TO DIAMETER 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.
IN,'
ater Supply Well:
17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic 9 ft 14 fL 1 in. .010 .25" PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fa ft. in.
Industrial/Commercial Residential Water Supply(shared) ;-1g!GROUT,
rfl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: ft. ft.
Monitoring ®Recovery ft. ft.
ection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation19.SAND/GRAVEL PACK if a licableAquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
Aquifer Test nStormwater Drainage 5 fL 17 ft. Sand' 1Pour8 Pounds
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20;DRILL]INGILOG attach additional sheets if i1&WSd J
FROM TO DESCRIPTION color,hardness,soiUrock type,arain sim,etc.
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:1 1-22-21 Well ID#B-3 ft. ft.
5a.Well Location: ft. ft.
Biltmore Church ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ° c.x � ,`•-E I i'
103 Educationb Drive, Flat Rock, 28731 ft. ft. 6EC 0
Physical Address,City,and Zip ft. ft.
Henderson 9587690356 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lavlong is sufficient) 22.Certification:
35.293208 N 82.398782 W gj:e�� 11-23-21
6.Is(are)the well(s)E)Permanent or InTemporary Signature of rti ell atra or 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 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 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:OnR SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 14 A) 24a. For All Wells: Submit this fform within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 a 200'and 1@100') construction to the following:
10.Static water level below top of casing:7.19 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2.25 (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.)
E
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce'nter,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 tol 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