GW1-2023-02402_Well Construction - GW1_20230404

1
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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 380 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER If a livable)
Raymond Brown well Company, Inc FROM TO DIAMETER I TAICIINESS MATERIAL
Company Name
0 ft. 80 ft. 61/4 1 1° sd21 pvc
PRWL.2022���78 ' 16.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.
Water Supply Well: 97.SCREEN - -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Ileating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
lndustrial/Commeroial Residential Water Supply(shared) 18.GROUT
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
Monitoring EIRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL-PACK if applicable)
'
- Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology f3Subsidence Control ft. ft.
Geothermal(Closed Loop) I3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Mother explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sciltmck type rain size,etc
0 ft. 20 ft, Red Clay
4.Date Well(s)Completed:6/8/22 Well ID# 20 ft' 55 ft Sand Rock -- ->-
5a.Well Location: ss 425 ft ft.
Blue Granite
Clayton Homes of Wilkesboro ft. ft. U o '
Facility/Owner Name Facility ID#(if applicable) ft. ft. J
Jim Hill Road --
ft. ft.
Physical Address,City,and Zip fL ft
Surry 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 6--L .) 6/8/22
6.Is(are)the well(s)OPermanent or E3Temporary 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: OYes or X No with I5A 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: 425 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if eli erew(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing:35 (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 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:
(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) 8 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: lsoz 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