_Well Construction - GW1_20230327 (16)

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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
4328-B .45 It. 5 ft.
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 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:WM0301267 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft 1 ft. .75 in. .25 Steel
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public 1 ft• 5 ft' 75 in. .006 .25 SS
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. None
x_ Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge -rIGroundwater-Remediation-
19.SAND/GRAVEL PACK(if ti licable) --'-
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test MStormwater Drainage ft. ft. None
Experimental Technology rISubsidence Control ft. ft.
Geothermal(Closed Loop) rITracer 20.DRILLING.LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM ft. TO
To DESCRIPTION color,hardness,sail/mck type,grain size,etc.)
4.Date Well(s)Completed:3-20-23 Well ID#B-5, B-7 fL ft.
e
Sa.Well Location: ft. ft. ['•�-� `'' �4�
Concrete Supply Co.LLC 00-0-0000012451 ft. ft. ~°
Facility/Owner Name Facility ID#(if applicable)
ft. ft. MAR 2 7 2023
200 West Graham St., Shelby, 28150 ft. ft.
Physical Address,City,and Zip ft. ft.
l^•.4 a r
Cleveland 2547102107 21.REMARKS
County Parcel Identification No.(PIN) Tempffary we!'.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.290129 N 81.542662 w 9 fA- /� 3-20-23
6.Is(are)the well(s) Permanent or Temporary Sign&fe&Weftifiej elly.ontractor 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: ®Yes or XINo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the native 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:TWO SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 1.67, 0.45 (ft.) Division of Water Resources,Information Processing Unit,
if water 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.)
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& 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. , i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016