GW1-2022-04697_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Bullins 14.WATER ZONES
-
Well Contractor Name FROM TO I DESCRRMON
4538
212 R• 213 ft. �
ft. ft.
NC Well Contractor Certification Number '45.OUTER CASING for 7!111 cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 30 ft- 61/4 f 1O' sdr2l pvc
Company Name d 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: EHWP2112-013 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. It- in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural []Mumicipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
I Industrial/Commercial DResidential Water Supply(shared) l8.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 21 ft Bentonite Pour
Monitoring C Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
6`19.'SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION rolor,Hardness,soiltrock type,grain size,etc.)
0 It. 12 ft- Soil
4.Date Well(s)Completed:4/22/22 Well ID# 12 ft. 265 ft. Blue Granite
5a.Well Location: ft. ft.
Juarez Perez ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
928 Cook Florist Rd ft. ft.
Physical Address,City,and Zip h' ft.
Rockingham 21.REMARKS
County Parcel Identification No.(PIN) MAY 12 202
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ty�rOCA0
(if well field,one lat/long is sufficient) 22.Certification:
N W P-L�_w 4/22/22
6.Is(are)the well(s)oPermanent or E3Temporary Signature of Certifkd 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 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: 265 (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 2Q100D construction to the following:
10.Static water level below top of casing: 33 (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) 20 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: 17Oz completion of well construction to Ithe 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