GW1-2021-00566_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Mason Bullins 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
45 ft. 46
4538
56 ft' 57 ft.
NC Well Contractor Certification Number 15.OUTER CASING for Mki cased wells OR LINER if applicable)
Raymond Brown well Company, Inc FROM TO DIAMETER T>IiclavEssI MATERIAL.
0 ft, 30 ft• 1 61/4 In' sd21 pvc
Company Name
2020-00002612 16.INNER CASING ORTUBING(geothermal
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. tt. in.
17.
Water Supply Well: FR CREE
MTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ 1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 24 it. bentonite pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
lAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Cooling Return) E3 Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rack type,grain size,eta
0 ft. 25 ft. soil
9/10/2021 ft. ft.
4.Date Well(s)Completed: Well ID# 25 85 bluegranite
5a.Well Location: ft. ft.
Douglas Potter ft. ft.Facility/Owner Name Facility ID#(if applicable) n ft. fL I J E C qq G 2 2.021
6301 Richland Church Rd. Liberty, NC 27298 ft. ft.
Physical Address,City,and Zip ft, ft.
Randolph .21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W (11(;I Jcil/1 0 LfetVl 0/21
6.Is(are)the well(s)OPermanent or ®ITemporary Signature ofCertifiLNd Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes 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 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: 85 (ft-) 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@1001 construction to the following:
10.Static water level below top of casing: 12 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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:
(Le.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) 50 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: 10oz 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