GW1--04273_Well Construction - GW1_20230626

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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
ft. ft. 1
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.UIC,County,State,Variance,etc.) 0 ft' 30 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
•Agricultural Municipal/Public 30 ft. 34 ft. .75 in. .006 .25 SS
II Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. - in.
•Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
MI'Monitoring QRecovery ft. ft.
Injection Well:
ft. ft.
®Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
NI Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•'Aquifer Test 0 Stormwater Drainage ft. ft.
*Experimental Technology 0 Subsidence Control ft. ft.
*Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
•Geothermal(Heating/Cooling Return) l Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed:6-8-23 Well ID#GW-3 ft. ft.
5a.Well Location: ft. ft -Y L�u i`' 1ti'-'w .-.-;'
•
ft. ft. I ,,�
J
Facility/Owner Name Facility ID#(if applicable) ft. ft. "I V
1 Hitachi Metals Drive, China Grove, 28023 ft. ft. Inv,:,,;.;; ;z_,, Pr '� '^,? 3 Una
Physical Address,City,and Zip
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 1at/long is sufficient) 22.Certification:
35.237098 N 80.869125 W
/` 6-10-23
6.Is are the wells i�Permanent or X Tern ora Signal of erufied ell C ntractolf� r Date
Is(are) () p ry
�'{ By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: lYes or ''IE No with 15A NCAC 02C.0100 or l5A 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-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: 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-3Ca 200'and 2@i00') construction to the following:
10.Static water level below top30.50
of casing: (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 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 the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016