GW1-2021-00579_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bullins 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
130 ft. 132 ft.
2312
350 ft* 353 ft. f
NC Well Contractor Certification Number 15.OUTER CASING formulti-cased;weRs OR LINER if a Gcable
Raymond Brown well Company, Inc FROM TD DIAMETER` THICKINESS MATERIAL
0 ft• 121 ft. 61/4 In' sd21 pvc
Company Name
16.INNER CASING OR TUBING eiithermallosed-loo `
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERL4,L
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. fL In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17i SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural []Mumcipal/Public ft. ft. in•.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial [IResidential Water Supply(shared) ':18 GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We1L• 0 ft• 20 ft• bentonite 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 C)Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed.Loop) Tracer 20 DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) E30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,limin size,etc
0 ft. 25 ft* soil
4.Date Well(s)Completed:2/1/2021 Well ID# 25 ft. 100 ft. sand
5a.Well Location: 100 ft. 445 ft. balace
Steve Hall
Facility/Owner Name Facility II1/#(if applicable) ft. ft. P E C 2 ? 2021,
2350 Flat Rock Road Reidsville, NC 27323 ft. ft.
Physical Address,City,and Zip ft. ft.
Rockingham 1L REMARKS :I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 22 a tcation t
N W h A /1/2021
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contrec or ate
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: ®Yes or ONo with 15A NCAC 01C.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 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: 445 (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@100D construction to the following:
10.Static water level below top of casing: 25 (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 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) 20 Method of test: sight 24c.For Water Supply&Iniectio'n 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: HTH Amount: 18oz completion of well construction to ithe county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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