GW1-2021-00584_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) i For Internal Use Only:
1.Well Contractor Information:
Phillip Mason Bullins 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4538 135 ft. 136 ft.
277 fi- 276 IL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a` Ifcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft 1 47 ft' 61/4 in. M21 pvc
Company Name
EHWP2106-007 16.INNER CASING:ORTUBING(geothermal'cliised400
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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. gale I pour
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3 Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and RecoverySalinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test E3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION color,hardnms,so0/rmk type,gmin size,etc
0 ft. 40 fL soil
4.Date Well(s)Completed: 10/11/2021 Well ID# 40 ft. 325 ft, bluegranite
5a.Well Location: ft. ft.
Benny Phipps ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft. a�
370 Kimbro Rd Reidsville, NC 27323 ft. fL - .
Physical Address,City,and Zip ft. ft. UEC2 2 2021
Rockingham 21.REMARKS
•� 4:I dr+d �++
County Parcel Identification No.(PIN) r �JSlivt7 �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W Ph * 10/11/2021
6.Is(are)the well(s)(3Permanent or E3Temporary Signature of Certified 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 MNo with 1 SA NCAC 02C.0100 or 1 SA 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 thisl form within 30 days of completion of well
For multiple wells list all depths(different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 (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 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.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 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: 17 oz 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
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