GW1--04010_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4328-B 13.09 rt. 20 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
JGDrilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. Ir
Company Name
70003211 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.U1C,County,State,Variance,etc.) 0 ft• 15 ft• 1.25 in. .250 Steel
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS NI 1 FERIA'.
DAgricultural °Municipal/Public 15 ft• 20 ft• .75 in" .006 .125 Stainless
°Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) - ft. ft. in
°Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
11 Irrigation FROM TO NI 1'I'ERI AL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring _ Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
El Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test DStormwater Drainage ft• ft• None
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:6-26-24 Well lD#GW-1 ft. ft.
5a.Well Location: ft. ft. , `- 1
IOS-PVB Holdings/Jeff Josephs ft. - ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3510 Robinson Circle, Charlotte, 28206 ft. ft. :�, �•�.,a„t.-.�;Mt
Physical Address,City,and Zip ft. ft. -nt9fii fr'rY( I_mot
Mecklenburg 08506130 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.259167 N 80.808820 W � �1� 6-27-24
6.Is(are)the well(s)DPermanent or X°Temporar� Signature r, ,t ed v, Con actor Date
By signing this form,1 hereby certity that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or ©No with 1SA 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#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:ONE SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing: 13'09 (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: 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& Iniection 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