_Well Construction - GW1_20230327 (68)

IF-Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bullins :14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
380 ft. ft.
2312
ft. ft.
NC Well Contractor Certification Number z45;OUTER CASING for multi lls OR LINER if a 'Gcable)
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 102 ft' 6114 rn sd21 pvc
Company Name
3677 �`36.,INNER CASING OR'TUBING 'eothermal closed-loop)
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.
I Well: �17.SCREEN'.
Water Supply Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'X Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) :18.:GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Four
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
-r:19:SAND/GRAVEL PACK if applicable)
-
-�-.. Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control tt. ft.
Geothermal(Closed Loop) E3Traeer 20.DRILLING LOG attach additional sheets if necessa =
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) 1 Other(explain under#21 Remarks)
0 ft- 30 ft* Red Clay
4.Date Well(s)Completed:4/22/22 Well ID# 30 ft. 97 ft. Sand Rock
5a.Well Location: s' ft. 425 ft. Blue'Granite
Adam Collins ft. ft.
�..
Facility/Owner Name Facility M#(if applicable) ft. ft. 2
1391 Locust Grove ft• ft.
Physical Address,City,and Zip ft. ft. ilii�+"°'`'r�,rr'J 'Z�
Stokes -2l.REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) 22.Certification:
N W 66 4 r 4/22/22
6.Is(are)the well(s)OPermanent or IOTemporary 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: InYes or ONo with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constructions 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: 425 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:70 (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 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 27699-1636
13a.Yield(gpm) 40 Method of test: sight 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit i 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.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016