GW1-2021-00481_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Mason Bullins WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4538 312 ft- 313 ft.
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER if a' licable
Raymond Brown well Company, Inc FROM �85
O DIAMETER THICKNE33 MATERIAL
0 ft,
ft 61/4 I° sd,21 pvc
Company Name q
1$J 1 '`16:INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: OJ FROM TO DUMETER 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 [3Municipal/Public ft• ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) f• ft. in:
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
I1Ti ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 22 ft, bentonite pour
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Gmundwater Remediation
19.SAND/GRAVEL;EAC&its livable
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eadn Cooling Return) E30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc
0 ft• 75 ft soil
4.Date Well(s)Completed: 11/5/21 Well ID# 75 ft. 605 ft* bluegradite
ft. ft.
5a.Well Location:
Brandon Wrisley
Facility/Owner Name Facility ID#(if applicable) ft. ft
4147 Quick Rd
Physical Address,City,and Zip ft. ft. 2
Caswell 21.REMARK,
County Parcel Identification No.(PIN)
1. R".Fssw uNr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: M
N W " cam 11/5/21
6.Is(are)the well(s)j3Permanent or ®ITemporary Signature ofCert1fied Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo with 15A NCAC 02C.0100 or 15A 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'Ihe 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 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: 605 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 65 (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 Injection 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) 2 Method of test: sight 24c.For Water Supply&IniectiIon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine lsoz
13b.Disinfection type: Amount: 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