GW1-2022-04675_Well Construction - GW1_20220512

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Rrint Forrn01
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
F
Phillip Bulllns 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
376 ft- 377 ft.
4538 ft. i
NC Well Contractor Certification Number
15.OUTER'CASING for multi-cased`wells ORLINER Ifs Gcable
Raymond Brown well Company, Inc FROM TO DIAMETER! THICKNESS MATERIAL
0 fL ft. 1 61/4 1 in' sd,21 pvc
Company Name
3689 16.INNER CASING OR TusING eotbermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER I 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. tt. in.
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it. in.
Industrial/Commercial OResidential Water Supply(shared)
18:-GROUT
f hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weil: 0 ft. ft. Bentonite Pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL:PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Imo'Stormwater Drainage ft, ft.
Experimental Technology ®I Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attacL additional sheets if necessary)
Geothermal (Heating/Cooling Return) E3 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
345 ft- 425 ft• Blue Granite
4.Date Well(s)Completed:4/19/22 Well ID# ft, ft.
5a.Well Location: ft. ft.
Merrill Perkins
Facility/Owner Name Facility fD#(if applicable) ft. ft.
1275 Dan River Shores Dr ft. ft.
MAY
Physical Address,City,and Zip ft. ft.
Stokes a21:REMARKS prCcooWg
County Parcel Identification No.(PIN) rkffill neeper LTV' O]WO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W P�),l.Clto 4/19/22
6.Is(are)the well(s)C)Permanent or Temporary Mature of Certifidd 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: ®Yes or ONo 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 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 00 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: 200 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) 40 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 19Oz completion of well construction to tithe 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