GW1-2022-04744_Well Construction - GW1_20220511

k P Int'Form �a'
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bulllns 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 780 k• 765 ft.
2312 k, IL
NC Well Contractor Certification Number 15.OUTER CASING for multi casediweRs OR LINER ifa licsble
Raymond Brown well Company, Inc FROM TD DIAII7ETERi THICKNESS MATERIAL
0 k. 4B ft. 6114 1O sd,21 pvc
Company Name
2022�22 -16.INNER'CASING ORTusING eothermalclosed-loo
2.Well Construction Permit#: 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. ft. in.
Water Supply Well: 17;SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,:
Industrial/Commercial DResidential Water Supply(shared) I&GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Chips Pour
Monitoring [)Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
19i SAND/GRAVEL PACK'if applicable
Aquifer Storage and Recovery 09alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [ITracer 20 DRILLING LOG'attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
0 ft. 20 ft, Red Clay
4.Date Well(s)Completed:4/11/22 Well ID# 20 ft. 41 ft. Sand Rock
5a.Well Location: 41 ft. 705 ft- Blue Granite
James Higgins ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
5401 Waller Rd ft. ft. MAY I
Physical Address,City,and Zip ft. ft.
Forsyth
21.REMARKS _1011110"ResonPirocofiling Lim
DWC?l M
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latflong is sufficient) 22.Certification:
N W l� ''I J 4/11/22
6.Is(are)the well(s)(3Permanent or [ITemporary 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: E]Yes or ONO with 15A NCAC 01C.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 ivell owner.
repair under 921 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: 705 (ft) 24a. For Ail Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a200'and 2Q100D construction to the following:
10.Static water level below top of casing: 37 (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) 2 Method of test: sight 24c.For Water Supply&Injection 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: soot completion of well construction to{the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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