GW1-2021-00656_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
Phillip M BuiilnS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
121 ft. 122 ft.
4538
ft. fa �
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 70 % 61/4 In. I sd21 live
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: PRWL202101801 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): 17.
ft' ft' rn
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaVPublic ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- P8 ft. Cement Cement truck
Monitoring D Recovery
Injection Well:
ft. ft
3 Aquifer Recharge E3Groundwater Remediation
;99:SAND/GRAVEL'PAGK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology []Subsidence Control ft. ft
i
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional,sheets if.necessa
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock a rain s' etc.
0 ft- 65 ft SoiUSandiock
4.Date Well(s)Completed: 11/24/21 Well ID# 65 ft 225 IL Bluegranite
ft. ft
5a.Well Location: _
Janet Sutphin ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1076 Zephyr Mountain Park Rd ft. ft
DEC 22
Physical Address,City,and Zip ft. ft
$Ufry :21.REMARKS I
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: /y� n
N W 11/24/21
6.Is(are)the well(s)oPermanent or [3Temporary Signature of Certffied 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: [3Yes or MNo 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 ito provide additional well site details or well
construction,only I 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: 225 (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 2@100D construction to the following:
10.Static water level below top of casing:43 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) 50 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: 12oz 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
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