GW1--04277_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.
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. 10 ft. 1 ;in. .25 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Ill Agricultural 0Municipal/Public 10 ft' 20 ft. 1 .010 .25 PVC
1111 Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
11
1 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT .
i 1 Irrigation FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
ES Monitoring D Recovery ft. ft.
Injection Well:
ft. ft.
U Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
ill Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD_
11•Aquifer Test OStormwaterDrainage 8 ft. 20 ft. #2 Sand Pour
II Experimental Technology DSubsidence Control ft. ft.
ir Geothermal(Closed Loop) I❑Tracer 20.DRILLING LOG(attach additiional'sheets if necessary)
-- FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
L- Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft.
•
4.Date Well(s)Completed:6-7-23 Well ID#GW-7 ft. ft. eC r `t.z 1 . r-•^
5a.Well Location: ft ft JUN 2Lv 2023
ft. ft.
`^--
Facility/Owner Name Facility ID#(if applicable) ft. ft. irl\VI?{;•;S::C it ?C�` :✓:41::`�Un-;(
1 Hitachi Metals Drive, China Grove, 28023 ft. ft. Gv;;;rr`i,N.,.
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:
35.572509 N 80.549633 W ;L/ t� ,t- 6-10-23
r Signature a We on ctor Date
6.IS(are)the well(s) IPermanent or IX Temporary
By signing this form,I hereby cent fy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo 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#11 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@100') construction to the following:
10.Static water level below topof casing: 11.05 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 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&Iniectionl 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. 1 1
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016