GW1-2021-06245_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Philip R. Hensley 14.WATExzoiv>rs =; °}w� .c�..;�
Well Contractor Name FROM TO DESCRITMON
175 f4 185 it 1 409M
3541 ft fl,
NC Well Contractor Certification Number
;15.'OUTER'CASiNG,for multl.casedwdls
Hensleyrs Well Drilling Inc. FROM To DMAWI R TmCNNM MATERIAL
1+ ft. 47 fL 6114 in. ..0210 PVC
Company Name
355790 F16:, xcasnI - 11 11r nv 'eotheririal?elosedaoo'. ,
2.Well Construction Permit#: FROM TO DIAMETER THICICNFM MATERi L
List all applicable well construction permits(.e.VIC,County.State.Variance,etc.) ft. iL in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: °FR'SCREEN IC
FROM TO. � !�DIAMETER' SUEr• SLOT S TffiCEIVFSS I MAT MAT ERIAL v
Agricultural [3Municipal/Public ft. & in.
Geothermal(Hcating(Cooling Supply) JaResidcntial Water Supply(single) fL fL in.
Industrial/Commercial OResidential Water Supply(shared) ]R GRO1T1
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 3 % cement pumped
Monitoring Recovery 3 ft- 20 ft. bentonite pumped
injection Well:
ft ff.
Aquifer Recharge 13Groundwater Remediation
19:iSAND/GRAVEL$YA't'K� ;�lii�ble s�'a44
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT MEM01D
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology 13Subsidence Control ft &
Geothermal(Closed Loop) Tracer "20:DR1LL1NGD?1G itWcl idditioiial sbeeta if
Geothermal(Heating/Cooling Return) E30ther( lain under#21 Remarks) FROM TO DESCRm'ION color,bardness,soil/rock type,Sniin size,eta
0 % 10 R. dry red day soil
4.Date Well(s)Completed: 10/4/2021 Well iD#355790 10 ft• 45 ft. brown sedimentary rock
5a.Well Location: rs ft 185 % solid grey graritte
William Autry fi i1•
a•r
FacilitylOwncr Name Facility iD#(if applicable) !t ft -�
5208 Range Rd., Rougemont, NC 27572
Physical Address,City,and Zip ft. fL COGeSJ
Granville -21:P!KAltxs4.:K a
VIP"' �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minotes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.17 773 N 78.45 636 W C -
—1" 10/5/2021
6.Is(are)the well(s)OPermanent or 13Temporary Signature of dbtified Well Contractor 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: ®Yes or JMNo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of the ropy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of 1hisform.
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: ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (it•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3®200'and 2®100� construction to the following:
10.Static water level below top of casing:30 00 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: 6 (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
air rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: — construction to the following:
(ie.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) 40 Method of test: ng 24c.For Water SuDDIv&Iniectif n 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: hypochlorite Amount: s oz completion of well construction to the county health department of the county
where constructed
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources` Revised 2-22-2016