GW1--01903_Well Construction - GW1_20240325

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:- l
1.Well Contractor Information:
Jeffrey Grant 14.WATERZONES '
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Well Contractor Name i i'�' ' ' ,# FROM
fa TO
ft DESCRIPTION ,
r ��Le gn I, '
4328-B 2 2024 ft. ft.
NC Well Contractor Certification Number MAR 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
9 r Inf,:i-r.jz,n '
.w�+i�.: t,7S ft. ft. in.
Company Name l 3W+✓i ::� 1
WM0701316 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' 10 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
IDAgrieultural OMunicipal/Public 10 ft' 14 ft• .75 '"' .006 .25 SS
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in, .
Industrial/Commercial- . DResidential Water Supply(shared) 18.GROUT.
I)Irrigation ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
NoiaWater_Supply_Well: ft. ft. _
xoMonitoring 0Recovery ft. ft.
Injection Well: ft. ft.
ilAquifer RechargeEl Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer TestStormwater Drainage ft ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM l TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling -
g/ g Return) (Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed:3-18-24 Well ID#GW-1,2,3,4 ft. ft.
ft. ft. ,
5a.Well Location:
National Salvage & Servi ft. ft. -
Facility/Owner Name Facility 1D#(if applicable) ft. ft. ,
401 old Mount Olive Highway, Dudley, 28333 ft. ft.
Physical Address,City,and Zip ft. . - ft.
Wayne 2597086258 . 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:
35.332777 N 78.025385 W 161e4 li .
l ` 3-20-24
6.Is(are)the well(s)OPermanent or xoTemporary- Signature Ceni ied We Con actor Date
By signing this form,I hereby certiAt that the well(s)was(were)constructed in accordance
7.Is this a repair town existing well: DYes or 0No 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 it formation 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:Four SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: 14 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:10.36 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Ceinter,Raleigh,NC 27699-1617
n
11.Borehole diameter: 1.5 (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 Celnter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Sunnily&Injection Wells: In addition to sending the form to
the address(es) above, also submit Ione 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