GW1--04300_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 14 ft. 18 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 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. 14 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 0Municipal/Public 14 ft. 18 ft• 75 in. .006 .25 SS
Geothermal(Heating/Cooling Supply) -Residential 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 0Recovery 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 DStormwaterDrainage ft. ft. None
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft. -
4.Date Well(s)Completed:6-15-23 Well ID#TW 4, TW-8 ft. ft. '
,.-.
5a. •
IA a
Well Location: ft. ft. tr ,ii,.a;i`LJ z�,
ft. ft.
J 1,iv 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
664 Old Hargrave Road, Lexington, 27295 ft. ft. 1,,,;;;is.sii c n Pl- -::.,2r„7,3 '-
ft. ft.
Physical Address,City,and Zip
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.Certification:
35.788295 80.311819 �,
6-16-23
6.Is are the wells Permanent or x Tern ora Signature22.07 -441-t-
Nactor Date
Is(are) () p ry
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 E3No with l5A NCAC 02C.0100 or l SA 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#2l 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: 18 (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(0100') construction to the following:
10.Static water level below top of casing: 14.03 (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 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016