GW1-2021-00647_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Phillip Mason Bullins 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ufi ft. „g ft.
4538
287 fL 288 ft.
NC Well Contractor Certification Number 15 OUTER CASING for multi cased'wells:OR LINER if a ticable
Raymond Brown well Company, Inc FROM TO DIAMETER', THICKNESS MATERIAL
0 ft. 70 ft. 6.1/4 " 1 sdr21 pvc
Company Name (�
prwIZOZ 1 O 1929 IC INNER CASING OR TusING eothermal'cl6sed-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): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in.,
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) fL fL in;
Industrial/Commercial Residential Water Supply(shared) 18;GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 30 ft bentonite! pour
Monitoring Recovery ft. ft.
Injection Well: ft fL
Aquifer Recharge E3 Groundwater Remediation
'19.'SAND/GRAVELPACK'if.a licable
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) E2Tracer 20.DRILLING-L'OG attach'additional sheets'if necessa
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soft/rock type,grain size etc.
0 ft- 65 ft. soil
4.Date WeR(s)Completed:8/24/21 Well ID# ft. % sandrock
5a.Well Location: 65 ft. 325 ft- granite
Donald Steele ft_ ft.
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Facility/Owner Name Facility ID#(if applicable)
ft. ft.
842 Stony Knoll Rd. Dobson, NC 27017 ft. ft.
Physical Address,City,and Zip ft. ft.
Surry 21.'REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification: J�
N `' l' t , 9/ 21
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor ! ate
By signing this form,1 hereby certify that the well(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
Ifthis 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 921 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 pageAo 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 if different(example-3Q200'and 2Qa 100) construction to the following:
10.Static water level below top of casing:60' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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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
(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) 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: Hth Amount: 18 completion of well construction to the county health department of the county
where constructed. f
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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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