GW1-2022-10705_Well Construction - GW1_20221205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JeffreyGrant
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4328-B
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased vells OR LINER if a licable
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. , in.
Company Name
WM01000530 FR INNER CASING OR TUBING eothermal closed-ES
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,State,variance,etc.) 0 ft. 15 It- 1.5 m- .25 Steel
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN '
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural ®MunicipaVPublic 15 ft- 19 ft- .75 in. .006 .25 SS
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
V
ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: ft. ft.
itoring -- -[]Recovery - - ft. -. -.- ft.on Well: fft. ft.
ifer Recharge Groundwater Remediation19.SAND/GRAVEL PACK(if a licableifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO Other(explain under#21 Remarks) ft. fr. DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed:1 1-14-22 Well ID#GW 1 ft. ft. _� �" R,1-gr�
ft. ft. ,"t �, 0 ate.a V F_a&)
Sa.Well Location:
Winter Bell Comapny ft. ft. DEC J h 9077
Facility/Owner Name Facility ID#(if applicable) ft. ft.
17 Truckers Place, Asheville, 28805 ft. ft. 1nv:;;Fr!&*t371 rr
Physical Address,City,and Zip ft. ft.
Buncombe 965863432 21.REMARKS
County Parcel Identification No.(PIN) TernporaFy well.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C ification:
35.577350 N 82.510519 W
11-14-22
6.Is(are)the well(s)IoPermanent or xMTemporary Signfifure of Certifie If Wel Contractor 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: rJYes or X)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and arplain the nature of the copy of this record has been provided to the well owner.
repair ender 921 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 I 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: 19 ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For nuhtple wells list all depths ifdifferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 15.33 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
5" '
11.Borehole diameter: 1. (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 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. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016