GW1-2021-00585_Well Construction - GW1_20211222

";�PC,int 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
280 ft- 405 ft.
4538
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells ORLIIVER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 ft- 61/4 sd2l pvc
Company Name
E I I W P2107-023 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.UIC,County,State,Variance,etc.) ft. ft• I In
3.Well Use(check well use): ft. tt. in.
Water Supply Well: .17 SCREEN
FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. fL in..
IndustriaUCommercialE3Residential Water Supply(shared)
]S.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole plug pour
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.:SAND/GRAVEL:PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidencc Control ft• fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) E30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock rain size,etc
0 ft 20 % red day
4.Date Well(s)Completed: 10/7/21 Well ID# 20 ft. 65 ft' sand rock
Sa.Well Location: 65 ft. 405 ft- blue granite
James Neal ft. fL
a»
Facility/Owner Name Facility ID#(if applicable) ft. fL d
290 Donathan Rd Reidsville, NC 27323 _
Physical Address,City,and Zip ft. fL DEC 2
Rockingham 21.REMARKS
County Parcel Identification No.(PIN)
R;.>~i,fKyo
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S- t
(if well field,one lat/long is sufficient) 22.Certification:
N W � 10/7/21
6.Is(are)the well(s)(3Permanent or Temporary Signature of Certifi Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• [3Yes or ONo with 15A NCAC 02C.0100 or ISA 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: 405' ft
P ( 24s. 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: 15 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•' ' 1617 Mail Service Center,Raleigh,NC 27699-1611
11.Borehole diameter: 6 (in.) 24b.For Injection 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) 15 Method of test: sight 24c.For Water Supply&Iniectilon 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: 16oz 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