GW1-2022-04661_Well Construction - GW1_20220512

i
Print Form Y
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: d
Chris Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312
250 ft• 255 ft.
o fL o rL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER 1f a" Iicable
Raymond Brown well Company, Inc FROM To DIAMETER THICICNEss MATERIAL
Company Name t,
0 97 t. i 61/4 , 1" sd21 pvc
3669 1F66 NNER CASING OR TUB DIAMETER
(geothermal closed-loop)
2.Well Construction Permit#: TER 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 13MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft. in.
Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT -
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. Chips Pour
j Monitoring DRecovery ft, ft.
Injection Well:
ft. ft.
JI Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK d applicable
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer =.20.-DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM T 3 DESCRIPTION(color,hardness soil/rocke, rain size,etc
0 ft. 6 ft Soil
4.Date Well(s)Completed:4/12/22 Well ID# 38 ft. 90 ft. Sand Rock
5a.Well Location: so ft 265 ft. Blue Granite
Leon Inman ft. ft r— .
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Fox Hills ft. ft.
Physical Address,City,and Zip ft. ft. U
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 o u�3 �� 4/12/22
6.Is(are)the weil(s)13Permanent or 13Temporary Signature of Certified 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: EJYes or E No 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: 285 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
I
10.Static water level below top of casing: 70 (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:
(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) 40 Method of test: sight 24c.For Water Supply&Iniectiori Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131b.DIsinfection type: HTH Amount: 1t10z completion of well construction to 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
!