GW1-2021-00626_Well Construction - GW1_20211222

Fri:t Foram
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Mason Bullins 14.WATER ZONES
WellContractor Name FROM TO DESCRIPTION
4538 873 ft• 674 ft.
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for ulti•cased'wells R OR LINE if a'licable m
Raymond Brown well Company, Inc FROM TO DIAMETER THICK MESS MATERIAL
0 ft. 30 ft- 61/4 in' sd2l pvc
Company Name
3532 16:INNER CASING OR TusING(geothermal dosed-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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural C)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft.
Industrial/Commercial Residential Water Supply(shared) 18rGROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 ft. bentonite
Monitoring EIRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3 Groundwater Remediation '
79.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft.
Experimental Technology ,Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets'if necessary)'
Geothermal eatin Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type rain size,etc
0 ft. 25 IL soil
4.Date Wel(s)Completed:9/2/2021 Well ID# 25 ft. 690 ft* blue granite
5a.Well Location: ft. ft
Anthony Pyrtle ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1515 Hall Rd.Westfield
Physical Address,City,and Zip % it.
Stoles 21.REMARKS 1
County Parcel Identification No.(PIN) I nrill deeper -^^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i i?JI
(if well field,one lat/long is sufficient) 22.Ce ICati0
N W - <. 10/5/2021
6.Is(are)the well(s)IDPermanent or Temporary Signature of Certified Well Con ctor 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: E3Yes or E3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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: 690 (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(Qa 100) construction to the following:
10.Static water level below top of casing:201 (ft.) Division of Water Reso Irces,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
1
13a.Yield(gpm) 25 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlorine
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: eoz completion of well construction to fire 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