GW1-2021-00513_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Mason Bulllns "14.WATER ZONES '
Well Contractor Name FROM TO I DESCRIPTION
275 ft- 285 ft
4538 318 ft' 319 It.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a 'ticable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft 45 ft 61/4 1° sdf21 pvc
Company Name
2021000032 16,INNER CASING OR TUBING eothecmal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft,
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 35 ft• bentonitei pour
Monitoring .Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EI Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) Otber(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,soil/mck type,gnins etc.
0 ft. 10 ft, soil
4.Date Well(s)Completed:9/16/2021 Well ID# 10 ft 345 ft. bluegranite
5a.Well Location: ft. tL
Tom &Karen Knox ft. ra
Facility/Owner Name Facility ID#(if applicable) ft. ft.
112 Harbor Dr. Denton, NC 27239 ft. rL 01.
Physical Address,City,and Zip rt. f`' DE
Davidson 21.REMARKS
County Parcel Identification No.(PIN)
INFOWM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi
N W 9-16-2021
6.Is(are)the well(s)OPermanent or OTemporary Signature ofCertified 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: []Yes or E)No 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 the well owner.
repair under#11 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: 325 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Qa 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 fort 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) 25 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: 17oz 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