GW1-2021-00512_Well Construction - GW1_20211222

P,�`rin't Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J
Phillip Mason z3vilt0As 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTTON
4538 198 ft. 199 ft.
210 ft. 211 ft•
NC Well Contractor Certification Number I5.OUTER CASING for multi-cased wells OR ca LINER if a lible
Raymond Brown well Company, Inc FROM TO DIAMETER THLCICNESS MATERIAL
0 ft. ft- 61/4 j 1° sd2i pvc
Company Name '
2021000069 16.INNER CASING OR TUEING(geothermal closed-loo
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.
77.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERI I AL
Agricultural [3Municipal/Public ft. ft. in;
Geothermal(Heating/Cooling Supply) J@Residential Water Supply(single) it. ft. in
Industrial/Commercial 13Residential Water Supply(shared)
18:GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 26 ft• bentonite pour
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG'attach addition Al sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rocke, rain size,eta)
0 ft. 5 ft* soil
4.Date Weli(s)Completed: 10/14/21 Well ID# 5 ft. 245 ft. granite
pn to—in,
5a.Well Location: '
David Schuler ft. ft. DEC
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
Emmons Mine Rd Denton, NC 27239 ft. IL 8 ( lii 11
Physical Address,City,and Zip ft. ft. '
Davidson 21.REMARKS -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W ��� � 10/14/2021
6.Is(are)the well(s)(IPermanent or Temporary S gnature ofCerdfied 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: ®Yes or NNo with 1 SA 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 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: 245 (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:42 (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) 12 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: 14oz 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