_Well Construction - GW1_20230327 (72)

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bullins 14.WATER ZONES
We1lContractor Name FROM TO DESCRIPTION
a gaff. a
2312 qa ft
fr. ft.
NC Well Contractor Certification Number I5.OUTER CASING for multi cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 44 ft. 61/4 1° sdr2l Pvc
Company Name
3476 rlb.INNER CASING OR TUBING(geothermal closed-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 DMunicipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.'GROUT..
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
Monitoring DRecovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge DGroundwater Remediation '49.'SAND/GRAVEL PACK if a licable .
Aquifer Storage and Recovery l0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. %
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional'sheets if necessa
RFROM TO DESCRIPTION color,hardness,soillrock e, rain size,etc.)
Geothermal(Heatin Cooling Return) (-- Other explain under#21 Remarks)
0 ft- 20 fL Red Clay
4.Date Wells Completed:5/6/22 Well ID# 20 ft. 39 ft.
() p Sand Rock
5a.Well Location: 39 ft. 325 ft- Blue Granite ,
Nathan Carmichael ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR 9, r
1581 William Fowler Rd ft. ft. `
Irl?vii'ii !tiSl ,71�fr:`
Physical Address,City,and Zip ft. ft
Stokes 21.'RE1gARKS."-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W 5/6/22
6.Is(are)the well(s)oPermanent or ®ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IOYes or RR No with ISA NCAC 02C.0100 or ISA 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 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: 325 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if eli ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:50 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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) 50 Method of test: sight 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 8oz completion of well construction t6 the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016
I