_Well Construction - GW1_20221207 (2)

w
®,
NORTH CAROLINA
ilk
WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Is this a revision to the form you have previously submitted?*
Yes No
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
..........................................................................................................................
Contact Name* Email Address*
Raymond Brown Well Co [e-mail]
Please provide the ID#for the GW1 for that needs to be revised.
G W 1-2022-09717
WELL CONSTRUCTION INFORMATION
1.Who is installing these wells?*
Owner Well Contractor
Please input your well contractor certification number to lookup your information.Once you have filled in the number,
hit the tab key to begin the lookup.*
4538
1.Well Contractor Information:
Certificate# Cert Level First Name Last Name Company Name
4538 Phillip Bullins Raymond Brown Well Co
2.Well Construction Permit#:
......................................................................................
WJW4418-1
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well (includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#

Date Well Completed* Well ID# Well Yield
10/18/2022 7
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Jeremy Plybon Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Rockingham 804000155191
Physical Address* Street Address
9740 NC-700
Address Line 2
City State/Province/Region
Pelham NC
Postal/Zip Code Country
27311 US
Latitude* 36.5162681000 Longitude*-79.5458122000
Decimal degrees Decimal degrees
........ ................ ......... ........................... ........................... ......... ......... ......... .....
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
525 surface?
For multiple wells list all depths if different 72
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
7 13a. Method of test:
If applicable sight
13b. Disinfection type:* 13b.Amount:
chlorine 16 oz

14.WATER BEARING/FRACTURE ZONES
From To Description
unknown 480
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 72.00 6.25 sd pvc
in feet in feet in inches
17.SCREEN
.................................................................................
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 20.00 Hole Plug pour
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 20.00 Red Clay
in feet in feet
20.00 67.00 Sand Rock
in feet in feet
67.00 525.00 Blue Granite
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.

23.Certification*
Signature of Certified Well Contractor
Submittal Date 12/7/2022