GW1-2021-00645_Well Construction - GW1_20211222

f
i Print FormX.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Phillip Mason Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4538
398 ft- 399 ft. l
ft. ft
NC Well Contractor Certification Number '15.OUTERCASING for,T!L1dtased'wells ORLINER if a' licabie
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 41 ft. 61/4 in. sd21 pvc
Company Name
PRW L2O21 00181 16.INNER CASING OR TUBING eothe�mal closed-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 OMunicipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
Irri ation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 21 ft. bentonite Pour
Monitoring E3Recovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [)Tracer 20.DRILLING LOG(attach raddition al'sheets if necessary)
~'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,gmin size,eta
0 ft• 35 fL soil
10/7/2021 ft. ft. •`
4.Date Well(s)Completed: Well ID# 3s azs bwegranito
Sa.Well Location: ft. ft.
Travis Money ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Still Meadows Ln �Tk�isIrtrG rC ;
Physical Address,City,and Zip ft. ft.
Surry 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 ­P% A YU4ET/2021
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Will 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: []Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 i
9.Total well depth below land surface: 425 (ft.) 24a. 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 1@100D construction to the following:
10.Static water level below top of casing: 150 (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 Infection 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) 4 Method of test: sight 24c.For Water Supply&Iniecti Ion 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: 1 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016