GW1-2022-04729_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris Bullins 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
260 ft. ft.
2312
o tL o ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 1 46 ft 61/4 i° sd21 pvc
Company Name
ZOZ OOOOH9 16.INNER CASING OR TUBING eothern al dosed400
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well consducuon permits Cue.UIC,County,State,Variance,etc.) ft. ft. 1°•
3.Well Use(check well use): fL It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft• ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft•
lndustrial/Commercial DResidential Water Supply(shared) it.GROUT
!ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- Q fL Hole Plug' Pour
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Croundwater Remediation
19.SAND/GRAVEL PACK ifs livable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardn soil/rack e, rain s' etc.
Geothermal Coo' Return) Other(explain under#21 Remarks) o ft. 20 ft, Red Clay
4.Date Well(s)Completed:3/29/22 Well 11)# 20 ft• 41 ft- Sand Rock
5a.Well Location: 41 ft 305 ft Blue Granite
Bryan Wallace rt ft
Facifity/Owner Name Facility ID#(if applicable) ft. fL Z
1107 Regan Rd ft. ft
Physical Address,City,and Zip ft. ft.
Davidson 21.REMARKS roc
DW0400
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tattlong is sufficient) 22.Certification:
N w 6Wt'�5 3/29/22
6.Is(are)the well(s)oPermanent or E3Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo with 1 SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the ropy of this record has been provided to the well owner.
repair wider#21 remarks section or on the back of/his 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: 305 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 t@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 39 VQ 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 Insertion 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 276994636
13a.Yield(gpm) 50 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: HTH Amount: eoz 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