GW1--01881_Well Construction - GW1_20240322

Print Form 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JeffreyGrant
14.WATER ZONES i '
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 ap licable)
JG Drilling,LLC FROM TO DIAMETERTHICKNESS 1 MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
WM0601286 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) 0 ft 21 ft• 1.5 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 21 ft• 25 ft• .75 in. .006 .25 SS
Geothermal(Heating/Cooling Supply) DResidential 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. •
x Monitoring ©Recovery ft. ft.
lnjectionWell: -- - - _ - -
ft. ft. -7
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery fDSalinity Barrier FROM ' , TO . MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology I0Subsidence Control ft. ft. -
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [(Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft.
3-5-24 GW-1,GW-2 ft. ft.
4.Date Well(s)Completed: Well ID#
t
ft ft. i-UG1a
5a.Well Location: % C.._1, r,� r J p.
ft. ft. f j
Facility/Owner Name Facility ID#(if applicable) ft ft. M A D e.: .
7988 US-52 South, Morven, 28119 ft ft. lnfoar-fir 1 Pr-::s.c Limn,link
Physical Address,City,and Zip ft. ft. Utilleu%'
Anson 21.REMARKS
County , Parcel Identification No.(PIN) Temporary well. .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
34.862275 N 80.00077 �,
3-6-24
6.Is(are)the well(s)OPermanent or x®ITemporary Signature e t WeI on cto 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 DYes or- xoNo with 15A NCAC 02C.0100 or 1SA 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: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths ifdiffrrent(example-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing:21 (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: (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&Injeition 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.
r
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources. Revised 2-22-2016