GW1-2022-04654_Well Construction - GW1_20220512

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Fr-irt;Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
371 ft- 372 ft.
4538
o rt. o rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a` Gcable
Raymond Brown well Company, Inc FROM I TO I DIAMETER I THICKNESS MATERIAL
0 ft- 37 ft 61/4 � In I d21 pvc
Company Name
FRWL202200868 16.INNER CASING OR'TUBING. eothermal dosed-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 []Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) IL ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 lt- 27 ft* Bentonite Pour
:)Monitoring 13Recovery ft. ft.
Injection Well: ft. fL
Aquifer Recharge E3Groundwater Remediation
19:SAND/GRAVEL`PACK if a" licable ''
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0 ft. 25 ft. Soil
4.Date Well(s)Completed:4/20/22 Well ID# 25 ft• 385 ft, Blue Granite
5a.Well Location: k. ft.
Josh Holder f`
,
Facility/Owner Name Facility 1D#(if applicable) IL I
110 Oriole Way ft. s
MAY
Physical Address,City,and Zip ft
Stokes 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 4/20/22
6.Is(are)the well(s)oPermanent or Temporary Signature of Certi,ed Well 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: DYes or ONo with 15A NCAC 02C.0100 or ISA 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: 385 (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@100� construction to the following:
10.Static water level below top of casing:66 (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 Injection 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) 5 Method of test: sight 24c.For Water SuDDIV&Iniecti Cn 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: 17oz completion of well construction tol the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016