GW1-2021-00576_Well Construction - GW1_20211222

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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 289 ft• 290 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER i£a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 61 ft- 61/4 in sd21 pvc
Company Name `16.
t� e
E H V V P21 07-021 INNER CASING OR TUBING eothermaCclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 7T&GROUT
hn ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 22 ft• bentonite pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3 Groundwater Remediation
19 SAND/GRAVEL PACK if:a Iica6le
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 29 DRILLING LOG attacHadditional,sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,soiI/mck a in size,etc.
0 ft• 55 % soil/sandrock
4.Date Well(s)Completed:8/16/21 Well ID# 55 ft• 325 It- bluegraniie
ft. ft.
5a.Well Location:
Brian Shacklock ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 22 2021
368 Cook Florist Rd Reidsville, NC 27320 ft. ft.
Physical Address,City,and Zip ft. ft
Rockingham :21'REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tattlong is sufficient) 22.Certification:
N W k '�n r f 1 2021
® U' IC_A �I/1 �!�J.
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified II 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 EJNo 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 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: 325 (ft-) 24a. For All Wells: Submit this',form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing:45 (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: 6 (in.) 24b.For Iniection 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 Method of test: sight 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: Chlorine Amount: 17Oz completion of well construction to tithe county health department of the county
where constructed. !
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016