GW1-2021-00655_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
G
Phillip M Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4538 374 ft. 375 ft. I
403 rL 404 ft.
NC Well Contractor Certification Number 15:OUTER CASING for multi-cased!Wells), B LINER if a' licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. 150 rL 61/4 i°' sd21 pvc
Company Name
PRWL202001394 16.INNER.CASING:OR'TUBING eothermal 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. In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•
hldustrial/Commercial E3Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft. Bentonite Pour
Monitoring (-Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19:'SAND/GRAVEL-PACK if applicsble
Aquifer Storage and Recovery 13Salinity 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 additional sheets if necessary)-
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
I Geothermal(Heatin Coolin Return) ' Other(explain under#21 Remarks)
0 ft• 135 fL soil/sandrock
4.Date Well(s)Completed: 11/2/21 Well ID# 135 ft• 425 ft. Blue Granite
5a.Well Location:
Robert Williamson
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
146 White Sulpher Springs Rd ft. ft.
Physical Address,City,and Zip ft. f`.
Surry 21.REMARKS R
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 01j M 11/2/21
6.Is(are)the well(s)(IPermanent or E3Temporary Signature ofCe tified 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: ®Yes or MNo 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-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 if different(example-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1f 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:
(Le.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) 25 Method of test: sight 24c.For Water Supply&Infection 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: 18oz completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016