GW1--04272_Well Construction - GW1_20230626

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Print Form-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant 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 wells)OR LINER(if ap licable)
JG Drilling,LLC FROM TO DIAMETER THICKNESS 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' 31 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
II Agricultural Municipal/Public 31 ft- 35 ft. .75 in. .006 .25 SS
31 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in,
il Industrial/Commercial E3 Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
®iMonitoring E3 Recovery ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
•Aquifer Storage and Recovery 0 Salinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
al Aquifer Test 0Stormwater Drainage ft. ft.
•Experimental Technology ©Subsidence Control ft. ft.
•Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary).
FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.)
01 Geothermal(Heating/Cooling Return) 0Other(explain under#2I Remarks) ft. ft.
4.Date Well(s)Completed:6-9-23 Well ID#GW 13 ft fr.
5a.Well Location: i"''"t ..a k t ji _.
ft. ft. -
- (�
Facility/Owner Name Facility ID#(if applicable) ft. ft. J U N L 2023
1 Hitachi Metals Drive, China Grove, 28023 ft. ft.
1n,�,r�r^hint?r::°t.f�.� Uf t
Physical Address,City,and Zip ft. ft. C�+ j',ila a
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
4.
6.Is(are)the well(s)0Permanent or OTemporary Signatur d W C ctor Date
By signing this form,1 hereby certifii that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (®Yes or QNo with 15A NCAC 02C.0100 or 15A 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#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-I 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: 35 (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 a 100) construction to the following:
10.Static water level below top of casing:31.77 (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 Injection 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 theicounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016