GW1-2021-00637_Well Construction - GW1_20211222

t Print Form-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Mason Bullins 14;WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
365 ft- 366 ft.
4538
fL ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. (oa ft. 61/4 in sdr2l pvc
Company Name
3538 '16.INNER CASING OR TUBING eothermalclosed-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.
,SC
Water Supply Well: FROM REE TO DIAMETERI SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in;
_�Industrial/Commercial DResidential Water Supply(shared) 18 GROUT
MATERIAL EMPLACEMENT METHOD&AMOUNT
i Irrigation FROM TO
Non-Water Supply Well: 0 ft. 82 ft• bentonite pump
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
i Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E2Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ElTracer 20,DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r Other explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,so)Urock rain size,etc.)
0 ft. 50 M soil
4.Date Well(s)Completed:8/20/21 Well ID# 50 ft 445 fL bluegranite
5a.Well Location: ft. ft
Adam Lowe rt it
Facility/Owner Name Facility ID#(if applicable) ft. ft. DEC G 2 2021
3985 Hwy 268E Pilot Mountain 27041 ft. ft
Physical Address,City,and Zip ft. ft
Stokes 21.REMA tKS, "
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.Cgtifieation: r
N W A, n 1 V I AL(jC&" 120121
Cyr �tri1%I
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certi ed 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: 13Yes 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 f
depth below land surface: 445' (t
P ) 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@I00) construction to the following:
10.Static water level below top of casing:65 (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) 15 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: 18oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources[ Revised 2-22-2016