GW1-2021-00654_Well Construction - GW1_20211222

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ryPrint Form1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Phillip M BulllnS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
unknown ft• unknown %
4538
ft. % C
NC Well Contractor Certification Number :15.OUTER CASING for multi cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 60 ft- 6114 in sdr21 pvc
Company Name
PR11VL202102205 16.INNER CASING OR TUBING(geothermal dosed-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. In.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural E3Municipal/Public ft. ft, in.'
Geothermal(Heating/Cooling Supply) ROResidential Water Supply(single) fL ft.
Industrial/Commeroial 131tesidential Water Supply(shared) I&GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 21 ft. Bentonite Pump
Monitoring Recovery ft. fa
Injection Well:
k. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL`PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStor'mwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) EITracer 20.DRILLING LOG'attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) E30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0 ft. 55 ft* Soil/Sandrock
4.Date Well(s)Completed: 10/25/21 Well ED# 55 ft. 705 ft. Blue Granite
5a.Well Location: ft. ft m
Ricky Inman ft. f° DE
Facility/Owner Name Facility ID#(if applicable) ft. ft.
125 Myth Way Pilot Mtn. ft. ft. 36c1
Physical Address,City,and Zip ft. ft.
Su" 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W 10/25/21
6.Is(are)the well(s)13Permanent or OTemporary Signature ofCertifibd 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: Dyes or oNo with 15A NCAC 02C.0100 or 15A 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-I 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: 705 (fL) 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@100D construction to the following:
10.Static water level below top of casing:200 (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 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) 1/2 Method of test: sight 24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine ub completion letion of well construction to the coup health department of the county
13b.Disinfection type: Amount: p county eP b
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016