GW1--01696_Well Construction - GW1_20240315

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WELL CONSTRUCTION RECORD(GW-11 For Internal.Use Only:
1.Well Contractor Information:
Chris Sullins 14.WATERZONES 1I !
Well Contractor Name FROM TO DESCRIPTION
2312 NIA ft. f. I 1 .
ft. ft.
NC Well Contactor Certification Number 15.OUTER CASING(formulti-eased wells)OR LINER(if ap llcable)
Raymond Brown well Company, Inc FROM TO DIAMETER TrncxNEss MATERIAL
0 ft 80 ft. 6114 j :m• sd21 pvc
Company Name N/A 16.INNER CASING.ORTUBING(geothermal elased-loop)
2.Well Construction Permit FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable well construction permits(Le.UIC,County,Stale,Valiance,etc.) ft. ft. i I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SrBFeN
FROM TO DIAMETER SLOT SIPA THICENESS MATERIAL
Agricultural OMunicipal/Public it. g, In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tL ft in.
Industrial/Commercial QlResidential Water Supply(shared)
28.GROUT i !
- 3t Irrigation -- - — — -— -FROM -TO —-MATERIAL-- -EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well; 0 ft. 20 ft. Hole Plug Pour
Monitoring I°Recovtay ft g,
Injection Well:
Aquifer Recharge I°GroundwaterRemediation 19.SAND/GRAVEL PACK&applicable)
Aquifer Storage and Recovery lSalinityBawer FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stotmwater Drainage ft. ft. I
Experimental Technology EISubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING-LOG(aUachnddfionalsbeeisir -y)
FROM TO DESCRIPTION(color,hardness,soi/rncktype,grata sire,etc)
Geothermal(Heating/Cooling Return) Other(explain under 021 Remarks)
0 ft. 20 ft. Red Clay
4.Date Well(s)Completed: _'� -Weil ID# 20 it 63 ft sand Rack
C'z
Sn.Well Location: s, ft* 1080 ft. etas Gran ire 1-.'L e g i t.." `
Pete Denny ft. ft. i MAP. l 5 202
Facility/Owner Name Facility ID#(if applicable) ft. ft. I
1
Intersection of Angell Rd&Neil Rd,Madison ft. ft. UMlitiilwir ktpn -1r-x,�grDirt; �
ft. ft (:1.''.'t„�,;,.y, m
Physical Address,City,aad Zip I;
Rockingham _21.REMARKS . i.
County Parcel Identification No.(PIN) he',i/ 12) I rl`\k tun lC
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification: 1 ,
vg 1 y
N - W (s A
� €( r1q Q-g6-0 d
6.Is(are)the ivell(s)CJPermanent or 1 1Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the xell(s)was(were)constructed In accordance
7.Is this a repair to an existing well: °Yes or 1211No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200Well Construction Standards and that a
Ifthis is a repair,Jill out broom well construction information and explain the nature of the copy alibis record has been provided to the well owner.
repair under#21 remarks section or or: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: suawirrrAL INSTRUCTIONS ,
depth below land surface: 1080
9.Total well ( )
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(/100') construction to the following:
N/A
10.Static water level below top of casing: (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 Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 clays of completion of well
12.Well construction method: construction to the following:
(i.e,auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: 1636
of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) aMethod of test: sight 24c.For Water SuPPly&Ini Rion 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: lsac completion of well construction tol the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016