GW1-2022-06277_Well Construction - GW1_20220628

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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
30 ft 34 &
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
WMO3O1214 16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) 0 ft 30 ft. 1.5 in. .25 Steel
3.Well Use(check well use): ft. ft. in.
17.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 30 ft. 34 ft .75 in.
.004 .25 Stainless
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri atlon FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft.
x Monitoring DRecovery ft ft.
ft ft. `
Aquifer Recharge rlGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rl Other(explain under#21 Remarks) FROM ft TO ft. DESCRIPTION(color,hardness,soit/rock type,gmin size,etc.
4.Date Well(s)Completed:6-20-22 Well ID#GW-1'2,3 ft ft.
Sa.Well Location: ft ft.
Days Inn ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
4924 Sunset Road, Charlotte, 28269 ft ft. e ; ht
Physical Address,City,and Zip ft ft.
Mecklenburg 04123105 21.REMARKS
County Parcel Identification No.(PIN) emporary
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: iYaSU rintll(iF'l +lJ'.t+�+%''''Jd,v
35.307049 N 80.845961 W 226��ef!�
6-24-22
6.Is(are)the well(s)InPermanent or )Temporary Sign re ofCettifie ell ontractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or x]No with 15A NCAC 02C.0100 or 15A NCACO2C.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 R21 remarks section or on the hack 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:Thret=_ (M) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 34 (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:30.20 (ft,) Division of Water Resources,Information Processing Unit,
If waier level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.511
n.
(i ) 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 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016