GW1-2021-00568_Well Construction - GW1_20211222

Rrint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Phillip Mason Bulllns 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
385 ft• 386 ft.
4538
k. %
NC Well Contractor Certification Number 15 OUTER CASING for.multi-cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 It. 57 ft. 6.1/4 � to I Sdr21 pvc
202 -���� 673 :.16 INNER CASING OR TUBING 'eothermalsclosed-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): k. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public k. ft. in.;;
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) k, ft. in.
Industrial/Commercial E31tesidential Water Supply(shared) 18.GROUT
f hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 25 ft• bentonite pour
.monitoring E3Recovery ft. ft.
Injection Well:
k. k.
Aquifer Recharge Groundwater Remediation
19.'SAND/GRAyEL PACK011applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage k, ft.
Experimental Technology Subsidence Control k. ft.
Geothermal(Closed Loop) (Tracer 20.DRILLING;LOG(attach additional sheets if necessa
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM T 5 DESCRIPTION color,hardness,soil rock a raja size,etc.
0 k. 0 ft. soil
4.Date Well(s)Completed:9/8/21 Well ID# ft. ft. sandrock'
5a.Well Location: so ft. 405 ft- blue ranite
EHC Builders ft. ft. {
Facility/Owner Name Facility ID#(if applicable) k. It. p
4871 Liberty Grove Road Liberty, NC 27298 IL It. DEC 2 2.. 7121
Physical Address,City,and Zip k. ft.
Randolph 2L 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.Certi`ficaatio�n:,
N W �D.E'er- IkI202 1
6.Is(are)the well(s)OPermanent or ®ITemporary Signature of Certified 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: DYes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 Ito 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
i
9.Total well depth below land surface: 405 (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 1@100) construction to the following:
10.Static water level below top of casing: 55 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: (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) 10 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 tol the county health department of the county
where constructed. 6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016