Loading...
HomeMy WebLinkAboutGW1-2022-04631_Well Construction - GW1_20220512 . P"r nt°Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Phillip Bulllns 14.WATER ZONES FROM TO DESCRIPTION Well Contractor Name 371 ft• 372 tt. 4538 p 409 ft• 410 ft• I NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable i- Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESSI MATERIAL Company Name 0 ft. 115 ft 6 114 I 1 ' I d21 pvc _ FRW L202000413 16.INNER CASING OR TUBING(geothermal closed-loop). 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. 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural []MunicipatWbhc ft. ft. in. Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) fL ft. in. Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT _IrTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft• 23 ft. Bentonite Pour Monitoring pRecovery 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 DStormwater Drainage ft. ft. Experimental Technology D Subsidence Control ft. ft. Geothermal(Closed Loop) )Tracer 20.'DRILLING LOG attach additional sheets if necessary) Geothermal(Heating/Cooling Return) E30ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc 0 ft. 110 ft. Soil/Sandrock 4.Date Well(s)Completed: 10/28/21 Well ID# 110 ft. 425 ft. Blue Granite 5a.Well Location: ft. ft. Jason Massey ft. fr. I f V= Facility/Owner Name Facility ID#(if applicable) ft. fL 555 New Life Church Rd Physical Address,City,and Zip ft. ft ~al UW PrCCW=9 f1$! S U r'.� 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 P� 10/28/21 6.Is(are)the well(s)OPermanent or Temporary Signature of Cet fled 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: [3Yes or ONo with I SA NCAC 02C.0100 or 15A NCAC102C.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 421 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: 425 (fit-) 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@100) 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 m. ( ) 24b.For Infection 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) 3 Method of test: sight 24c.For Water Supply&Iniectioil 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: laoz completion of well construction to flee 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