GW1-2021-02561_Well Construction - GW1_20210805

i Prin Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JeffreyGrant
14:WATERiZONES
Well Contractor Name FROM ft TO ft DESCRIPTION
4328-B Soil Samples were not collected.
rt ft
NC Well Contractor Certification Number 15.,OUTER CASING:fiir m h cased;wells'ORILINERt ifs"lieable�" :
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 8 ft' 1.
5 in .25" 1 Steel
01 00493 .116."INNER CASINGiOR;TUBING "eottiermihclosed-loo
W
2.Well Construction Permit#: M FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.71C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water17;SCREEN
]Agri Supply Well: FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
_- Agricultural Municipal/Public 8 ft. 12 ft 75 "- .006 .25" SS
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18XROUT
lExperimental
ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-Water Supply Well: ft. rt.
onitoring____. Recovery_ ft• --- _.—ft.-- --- _ . --
--- - -
quife Well: 19..SAND/GRAVELYACKi ifa liceft ft.
quifer Recharge ®Groundwater Remediation
ble ,.vlquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test DStormwater Drainage ft. ft.
Technology Subsidence Control ft ft.
othermal(Closed Loop) Tracer 30:+DRIULING!VOGi'ittachladditioiialsheefs"if,necessaFROM TO DESCRIPTION color,hardness,soiL/mck min size,etc.othermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed:7-27-21 Well ID#MW-1 ft ft.
Sa.Well Location: ft ft. '
Joseph Wright Property ft ft. rlo\
Facility/Owner Name Facility ID#(if applicable) fL ft. C e7
5182 Boylston Highway, Mills River, 28759 ft ft. Q�ess
Physical Address,City,and Zip ft ft. 1 ,� Se44'1G
Henderson 21.`REMARKs �.� � _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
35.380426 N 82.575896 W
7-27-21
6.Is(are)the well(s)[3Permanent or X�_ Temporary Sigt re ertifi el .outractor 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: QYes or XJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 421 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:OnP_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 (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 a 200'and 2@I00') construction t0 the following:
10.Static water level below top of casing:8'67 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2.25 P
(in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Direct Push above,also submit one copy of thus'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
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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 to the county health department of the county
where constructed. fl
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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