GW1-2021-07638_Well Construction - GW1_20211201

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P;in Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Jeffrey Grant 14.WATER ZONES
Well Contractor Name FROM TO IDESCRIPTION
4328-B 1.89 IL 10 ft. i
ft. ft.
NC Well Contractor Certification Number
I5.'OUTER CASING,(fdr multi-cased,wells',0RLL_R1 if=`a` lic"able E
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft
1 ft. 1 to .`L5° PVC
WM0100502 16.INNER CASING=OR TUBING eofhertiriEclosea loo -
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS I 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural C]Municipa"ublic 5 ft- 10 ft• 1 in., .010 .25" PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.:
Industrial/Commercial Residential Water Supply(shared) 18siGROUT ,.;; ;ate_&
Fermal
ion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: ft. ft.
oring Recovery ft. ft.
n Well:
_ ft. ft. I
r Recharge Groundwater Remediation _
19.SAND/GRAVEL PACK if applicable)
er Storage and Recovery nSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test DStormwater Drainage 3 ft- 10 ft. Sand Pour 6 Pounds
imental Technology Subsidence Control ft. ft.
ermal(Closed Loop) Tracer -,10:DRILLINGLOG;iitac6additional1beetiif,necessa
l(Heating/Cooling Retum) MOther(explain under#21 Remarks) FROM ft ft.To DESCRIPTION color,hardness,soittrock type,grain size,etc.
4.Date Well(s)Completed:1 1-22-21 Well ID#B-1, B-2 ft. ft.
5a.Well Location: & ft.
Biltmore Church ft ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. P"� � .,p
103 Educationb Drive, Flat Rock, 28731 ft. ft.
Physical Address,City,and Zip
ft ft. u C 2021
Henderson 9587690356 21.REMARKS
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County Parcel Identification No.(PIN) CWIR SECTION
1��1-V� RNIATION PTIOCESSING UNIT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.294228 N 82.397730 W
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rt 11-23-21
6.Is(are)the well(s)13Permanent or Temporary Signa f ed I C tractor Date
By signing this form,I hereby certi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 19No 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 hack of thisform. 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:tWf) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing:6.68, 1.89 (ft.) Division of Water Resources,Information Processing Unit,
Iftvaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2.25 (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: P
(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 Supply&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. ,
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016