GW1--04279_Well Construction - GW1_20230626

II Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant -i4.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4328-B - ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
JG Drilling,LLC _FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WM0301288 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: - •
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) 0 ft. 15 ft- 1 in. .25 PVC
3.Well Use(check well use): ft. ft. in.
•
Water Supply Well: 17.SCREEN i __ -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural 0Municipal/Public 15 ft- 25 ft' 1 in. .010 .25 PVC
II Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
Industrial/Commercial D Residential Water Supply(shared) 18.GROUT •
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring [Recovery it. ft.
Injection Well: ft. ft.
Aquifer Recharge [Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IDAquifer Test 0Stormwater Drainage 13 ft- 25 ft- #2 Sand Pour
[Experimental Technology D Subsidence Control ft. ft.
'Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ilOther(explain under 421 Remarks) FROM TO i DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed:6-7-23 Well ID#GW-11&14 ft. ft.
5a.Well Location: ft. ft.
ft. ft. r~,C Lc IL d k1 "111
Facility/Owner Name Facility ID#(if applicable) ft. ft. JUN J C.', L�L�
1 Hitachi Metals Drive, China Grove, 28023 ft. ft.
Physical Address,City,and Zip ft. ft. Irk`'s;fei.C•i;'Cil ;fir.;:?.i;v,:l Ur,:.
Rowan 21.REMARKS :oS`,;Q; '.X.4
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
6-10-23
6.Is(are)the well(s)rPermanent or iX Temporary Signature a We on ctor Date
•
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: LiYes or ljNo with 1.SA 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 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:Two SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25 (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@200'200'and 2 a 100') construction to the following:
10.Static water level below topof casing: 15.11, 15.50 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&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.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016