GW1--04300_Well Construction - GW1_20230626 (2)

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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 12.5 ft. 16 ft•
ft. ft. 1
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
JG Drilling,LLC FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. in.
Company Name
WM0401453 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. 12 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 MI Municipal/Public 12 ft• 16 ft• 75 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 ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Et Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test rStormwater Drainage ft. ft. None
Experimental Technology EtSubsidence 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,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:6-15-23 Well ID#TW 1 ft. ft.
5a.Well Location:
ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
664 Old Hargrave Road, Lexington, 27295 ft. ft. rs w. -,
Physical Address,City,and Zip
ft. ft. i. 'r 4°...v+'L.ii V L_.?.,s''
Davidson 21.REMARKS ' JUN q 2023
•
County Parcel Identification No.(PIN) Temporary well.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "^,•jam;^�O;r
(if well field,one lat/long is sufficient) . 22.Certification:
35.788295 N 80.311819
6-16-23
6.Is(are)the well(s)DPermanent or x®ITemporary Si re ertifi el onhactor 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 ONo 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:One SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d fferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:12.5 (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
12.Well construction method:
Direct Push above, also submit one copy of this form within 30 days of completion of well
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