GW1-2021-00650_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Q
Phillip Mason Bullins 14.WATER ZONES -
FROM TO DESCRIPTION
Well Contractor Name
367 ft. 368 it.
4538 ft. It.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased-wells OR LINER ifs livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft 135 ft.
6114 1°' 'd21 pvc
Company Name
PRWL202102015 F6•Iiv1vER'cnslxGORTus AM eomermatelICKN S
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.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g• ft. ;°•
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 23 ft. bentonite pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
-19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater 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 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soi0rock in size,eta
0 f1• 90 ft soil
4.Date Well(s)Completed: 10/26/21 Well EW 90 ft. 130 ft. soil/sndrock
Sa.Well Location: 130 ft. 425 ft- bluegranite [
Jerry Corum ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. DE
2028 Fancy Gap Rd Mt Airy ft. ft.
Physical Address,City,and Zip ft. ft. ONj
furry 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 ejL_. /1 10/26/21
6.Is(are)the well(s)j3Permanent or .Temporary Signature ofCertifi6d Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
/f 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: 425 (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@I00) construction to the following:
10.Static water level below top of casing: 55 (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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 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: 21oz completion of well construction to the county health department of the county
where constructed. P
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016