GW1-2022-04689_Well Construction - GW1_20220512

"Prinf Foram-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bulllns 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
110 ft. ill ft. j
2312
320 ft, 322 ft.
NC Well Contractor Certification Number 75.OUTER CASING for multi-cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERUL
0 ft. 48 fL 6 1/4 ! in. sd21 pvc
Company Name
E H W P2107-034 16.INNER CASING OR TusING eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TH CKNESS 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 [3MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g ft.
Industrial/Commercial DResidential Water Supply(shared)
18:GROUT.
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Chips Four
:]Monitoring pRecovery ft. ft.
Injection Well:
rt. rL
Aquifer Recharge Groundwater Remediation
r� ]9.'SAND/GRAVEL PACK ifa livable
Lam'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3 Stormwater Drainage ft. ft.
Experimental Technology [ISubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,sollfrock type,grain size,etc.)
0 ft. 10 ft, Soil
4.Date Well(s)Completed:5/2/22 Well ID# 10 ft' 40 ft' Sand Rock
5a.Well Location: d0 ft. 50 ft• Granite
Donald Peoples 50 ft. 61 ft, Sand Rock
Facility/Owner Name Facility ID#(if applicable) 61 ft. ass fit. Granite
497 Planters Rd ft. IL
MAY 1
Physical Address,City,and Zip ft. f6 W-forma bon
Rockingham 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 1� 5/2/22
6.Is(are)the well(s)OPermanent or [3Temporary 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: ®Yes or Oi 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 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: 365 (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@1001 construction to the following:
10.Static water level below top of casing:50 (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 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 submif one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: �OZ 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