_Well Construction - GW1_20230327 (43)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip BUillns 14.WATER ZONES
'
Well Contractor Name FROM TO DESCRIPTION
4538 218 ft- 219 ft.
p k. p ft.
NC Well Contractor Certification Number
A5.OUTER CASING'for multi-cased wells OR LINER if a 7icable
Raymond Brown well Company, Inc FROM TO DIAMETER TLHCKNESS MATERIAL
p ft. 123 It- 6114 sd21 pvc
Company Name t16.INNER CASING OR TUBING Othermal closed-loop).
2.Well Construction Permit#: EHWP2112-018 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) ft. ft. fin.
3.Well Use(check well use): ft. ft. ln.
Water Supply Well: ;A7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural IOMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) iX Residential Water Supply(single) ft. ft. in•
Industrial/Commercial Residential Water Supply(shared) -A&GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 40 ft. Bentonite Pour
Monitoring [ Recovery ft. ft.
Injection Well:
ft
Aquifer Recharge E3Groundwater Remediation
19:'SAND/D/GRAVEL PACK if applicable)
'
Aquifer Storage and Recovery I3ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) f©ITracer 20.DRILLING LOG attach additional,sheets if necessary)".
FROM TO DESCRIPTION(color,hardness,soil/mck e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks
0 ft. 95 ft. Soil
4.Date Well(s)Completed:4/29/22 Well ID# 95 ft. 115 ft. Sand Rock
5a.Well Location: 115 ft 265 ft Blue Granite
Harry Lee Carter k. ft
Facility/Owner Name Facility ID#(if applicable) ft. fL
1360 Smothers Rd ft % MAR 2 i 20
Physical Address,City,and Zip ft. %
Rockingham
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 141dz ,� �(,�v� 4/29/22
6.Is(are)the well(s)oPermanent or ©ITemporary Signature of Certifiet 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: QYes or 'XX No 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 mid erplain 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 if different(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing:45 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 Injection 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) 25 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' 16oz 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