GW1-2021-00466_Well Construction - GW1_20211222

;Prilit Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Mason Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4538 229 ft. 230LILL
ft. ft. j
NC Well Contractor Certification Number ,45.OUTER CASING for multi-cased wells)OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER' THICKNESS MATERIAL
0 ft. 61 ft- 1 61/4 I in. galavanized
Company Name
4977WELN21 `-16.INNERCASINGORTUBING eothertnakdosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,Coun)4 State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 1z;SCREEN
FROM TO DIAMETER; SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. In.'
:)Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
hrdustrial/Commercial DResidential Water Supply(shared)
18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 I'L 22 ft• gentonite' pour
Monitoring pRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applies ble
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology ®)Subsidence Control
Geothermal(Closed Loop) ®)Tracer 20.DRILLING.LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wit/mek type,graln size,etc.
0 ft. 55 fL soil/sandrock
4.Date Well 11/10/21 s)Completed: Well ft,ID# 55 245 ft. Bluegrante
59.Well Location:
Kishia Swift ft. ft.
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft. DN SEGrON
6107 Apple Orchard Dr. Mebane ft. ft. !i`.°�"ORWTM PRMSM LArl
Physical Address,City,and Zip ft. ft.
Alamance 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:
N W PA 1, ,(,c 11/10/21
6.Is(are)the well(s)OPermanent or Temporary Signature ofCerti d 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: [3Yes or ONo with 1 SA 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#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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft-) 24a. For All Wells: Submit this`,form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing: 55 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For lniection Wells: In addition to sending the form to the address in 24a
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,U.�derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: sight 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: HTH Amount: 17Oz completion of well construction to`the county health department of the county
where constructed.
F
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016