GW1--04299_Well Construction - GW1_20230626

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor Information:
JeffreyGrant
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4328-B 12 ft. 15 ft.
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
WM 0401453 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. 11 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 Municipal/Public 1 1 ft. 15 ft. 75 in. .006 .25 SS
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. None
x Monitoring (Recovery ft. ft.
Injection Well: -- ---- - -- -
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft. None
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO _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-2, TW-6 ft. ft.
5a.Well Location: ft. ft.
ft. ft. rn _
i a
Facility/Owner Name Facility ID#(if applicable) ft. ft. 'i .L.�'L. V ?:.-•y:-•r
664 Old Hargrave Road, Lexington, 27295 ft. ft. JUN 9 ; ?113
Physical Address,City,and Zip ft. ft.
Davidson 21.REMARKS 11-1;v1r5":r...,1: .:..... ,>>.:rJ Li ,
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:
35.788295 N 80.311819 W
6-16-23
6.Is(are)the well(s) Permanent or x',Temporary Sigma e o -title ell ontractor 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: ElYes or E3No 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-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: 15 (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 top of casing: 12.12 (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 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 lone 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