GW1--04271_Well Construction - GW1_20230626

II Print Form 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant 14.WATERZONES
We11Contractor Name FROM TO DESCRIPTION
ft. ft.
4328-B
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
JG Drilling,LLC FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in.
Company Name
WM0301288 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.U/C,County,State,Variance,etc.) 0 ft* 20 ft• 1.5 in. .25 Steel
3.Well Use(check well use): ft ft in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural IDMunicipal/Public 16 ft• 20 ft .75 in' .006 .25 SS
0Geothermal(Heating/Cooling Supply) I0Residential Water Supply(single) ft. ft. in.
0Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
ri Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
iX Monitoring 0Recovery ft. ft.
Injection Well: '
ft. ft.
Aquifer Recharge ©Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
0Aquifer Storage and Recovery 0Salinity Barrier FROM TO , MATERIAL , EMPLACEMENT METHOD
0Aquifer Test 0Stormwater Drainage ft. ft.
©Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attach additional sheets if necessary)
QGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft.
4.Date Well(s) 6-9-23
Completed: Well ID GW 8 ft. ft.
# ' `fir',' ?'-r-,
5a.Well Location: ft. ft. r'„4-Le{I y l' F I �V C Li
---
ft. ft. �j�� 2023
Facility/Owner Name Facility ID##(if applicable) ft. ft.
1 Hitachi Metals Drive, China Grove, 28023 ft. ft. ink-,r'aict, Pr.•r 2' f. Unx
v
Physical Address,City,and Zip ft. ft.
Rowan 21.REMARKS
County Parcel Identification No.(PIN) Temporary well.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.237098 N 80.869125 W
6-10-23
6.Is(are)the well(s)0Permanent or i�x(Temporary Signat o feed ell ntractor Date
By signing this form,1 hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EjYes or iX No with 15A NCAC 02C.0100 or ISA 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 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:One SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (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 a 100') construction to the following:
10.Static water level below top of casing: 17.26 (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: 1.5" (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& Injection 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. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016