GW1--04297_Well Construction - GW1_20230626

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant 14.WATER ZONES
• Well Contractor Name FROM TO , DESCRIPTION
4328-B 16 ft. 20 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 1 MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:WM0401453 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 ft. 16 ft. 75 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 0 Municipal/Publ ic 16 ft. 20 20 ft. 755 in. .006 .25 SS
Geothermal(Heating/Cooling Supply) OResidential 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. None
x Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL , EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft. None
Experimental Technology 101Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM_ TO O DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)__
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:6-15-23 Well ID#TW-3, TW 5 ft. ft.
5a.Well Location: ft. ft. ``� �.
ft. ft. r C Li I. . V 1 5 .1
Facility/Owner Name Facility ID#(if applicable) ft. ft. JUN 2023
,)
664 Old Hargrave Road, Lexington, 27295 ft. ft.
f,_. ; .. 1
Physical Address,City,and Zip ft. ft. 1nr��.r a .n C-=r.,w:: 1:-�
Davidson 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.C I cati n'
35.788295 N 80.311819 W ff-44amt-
6-16-23
6.Is(are)the well(s)E1Permanent or EjTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fYes or jNo with I5A 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-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: 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-3L200'and 2@100) construction to the following:
10.Static water level below top of casing: 16.56 (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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016