_Well Construction - GW1_20230327 (81)

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312 480 ft. ft.
o ft. a rt.
NC Well Contractor Certification Number 15.'OUTER CASING for multi cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DKAIt�TER TRICKINESS MATERIAL
0 ft• 47 ff. 61/4 1° sd,21 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed400
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
X Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1tri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Hole Plug Pour
Monitoring f Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge EIGroundwater Remediation
?49.SAND/GRAVEEPACK if a licable`-
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG.attach additional sheets if necessa'
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) ( Other(explain under#21 Remarks)
0 ft- 20 fL Red Clay
4.Date Well(s)Completed:4/21/22 Well ID# 20 ft. 42 ft. Sand Rock
5a.Well Location: 42 ft. 525 fL Blue Granite
Joe Fulk fL ft.
Facility/Owner Name Facility MR(if applicable) ft. ft. h.:if:` :y''j—•,
2829 Horseshoe Rd rt, ft. MAR O
Physical Address,City,and Zip ft. ft.
Stokes >21.REMARKS.'..
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 Oytl� 4/21/22
6.Is(are)the well(s)oPermanent or I3Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: lYes or X No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,full out known well construction information and explain the nature ofthe copy ofthis 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-I 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: 525 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(200'and 2(Qa 100) construction to the following:
10.Static water level below top of casing: 70 (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 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:
(Le.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) 5 Method of test: sight 24a 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016