GW1-2023-02952_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print F__
1.Well Contractor Information:
Phillip Bullins 14.WATER ZONES.
Well Contractor Name FRObf TO I DESCRIPTION
4538 ft- 20o I
ft ft.
NC Well Contractor Certification Number
IS.OUTER CASING formulti-cased welts ORLINER If`a licable -
Raymond Brown well Company, Inc FROM TU DIAMETER THICIQIEss MATERIAL. -
Company Name g ft 1 67 ft 1 61f4 in. sdrzt pvc
W21-0378 16.INNER CASING ORTUBING eothermalclosed400 -
2.Well Construction Permit#: FROM To I DIAMETER I TRrcxNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft, in.
3.Well Use(check well use): ft. & in.
Water Supply Well: .17.SCREEN =
FROA1 TO DIMIETER SLOT SIZE THICKNESS DATERIAL
Agricultural OMunicipal/Public % ft. in,
Geothermal-(Heating/Cooling Supply) [Residential Water Supply(single) ft ft, in.
Industrial/Commercial - --- -QlResidentiat Water Supply(shafed)' --J -' ------ ---
18rGROUT
— l_
lni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 26 ft. Hole Plug Pour
Monitoring f Recovery pt, ft.
1- Geothermal
jection Well:
Aquifer RechargeGroundwater Remediation ft. ft.L'
19.SAND/GRAVEPACK ifa`- el.Aquifer Storage and Recovery ©ISahnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. %Geothermal(Closed Loop) i©ITracer 201DRILI;rNG LOG attach additionulsheets if necessa )(Heating/Cooling Return) - Other( lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sollrrock type rain size,etc.
0 ft. 55 `fL Sand Rock
4.Date Well(s)Completed:03/9/2023 Well ID# 55 ft. 245 ft.
granite
Sa.Well Location: ft. ft.
Joshua McDowell ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft. ft rI
Joshua McDowell ft. rt ---�•'
-Physical Address,City,and Zip ft ft. APR D L 70 Z)
1042 Richmond Road,Mebane, 2LREMARKS t t 1` - L J
County �/'a,��'�i Parcel Identification No.(PIN)
V r
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:"
(ifwell field,one latnong is sufficient) 22.Certification:
N W 03/09/2023
6.Is(are)the well(s)oPermanent or OTemporary Signature ofCemfied 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: QYes or X)NO with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and erplain the stature 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:
S.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 I 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: 245 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifd perent(example-3@200'and 2 aC3100) construction to the following:
10.Static water level below top of casing:48 (ft.) Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: sight 24c.For Water Supply&Injection 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: HTH Amount: t4oz, completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvimmmental Quality-Division of Water Resources Revised 2-22-2016