GW1--01987_Well Construction - GW1_20240401

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
Jeffrey Grant 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
21 ft 25 ft.
4328-B f I
t. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if apelicable)
JG Drilling,LLC FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. in.
Company Name
WM0301348 70003190 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 21 ft' 1.5 ' is .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 21 ft. 25 ft. .75 in. .006 .25 SS
Geothermal(Heating/Cooling Supply) El Residential 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.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ID Stormwater Drainage ft. ft. '
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g Other(explain under#21 Remarks) ft. ft. 1
4.Date Well(s)Completed:3-25-24 Well ID#GV1/1 & 2 ft. ft.
5a.Well Location: ft. ft. _ ,..,‘„Tr"' ;'7.--, ,...
McDonald's USA, LLC ft. ft. C.-.k. 4_0' .+ '(a, 4-Facility/Owner Name Facility ID#(if applicable) ft. ft. A P R 41 2024
13101 Idlewild Road, 28105 ft. ft.
Physical Address,City,and Zip ft. ft. lRgiir,j��is t1?'.s.`:•••: .',�f'•
�i4',FCtt•.L�+,9 r�
Mecklenburg 19501895 .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: •
35.137828 N 80.682307 W
3-26-24
6.Is(are)the well(s)DPermanent or Temporary Signa a rfied ell ntractor Date
By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
• 7.Is this a repair to an existing well: IDYes or x®No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and exploit;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
87
9.Total well depth below land surface: 21. ' 23.77 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service:Center,Raleigh,NC 27699-1617
5"
11.Borehole diameter: 1. _ (in.) 24b.For Infection 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.) j
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