GW1-2022-04639_Well Construction - GW1_20220512

in Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
a
1.Well Contractor Information:
Phillip Bullins 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4538 112 ft- 113 ft.
206 ft* 207 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased"we0s'ORLINER'rf:9 livable";
Raymond Brown well Company, Inc FROM TO DIAMETER' THICKNESS MATERIAL
0 ft. 50 IL 61/4 1° sdr2l pvc
Company Name
PRWL2�21�2rZ40 16.U14NER'CASING ORTUBING eothermaldosed-loo z
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: 11 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft. in
,Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
8>GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: () ft. 22 ft. Bentonite Pour
Monitoring E3Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 70
19.SAND/GRAVELPACK if applicable)
'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20 DRILLING LOG attach additional sheets if necessary)'
Geothermal(Heatin Cooling Return) E30ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type rain size,etc
0 ft. 30 fL Soil
4.Date Well(s)Completed: 11/23/21 Well ID# 30 ft 45 ft• Sand Rock
5a.Well Location: a5 ft. 225 ft- Blue Granite
ft. ft.
Gregory Inman
Facility/Owner Name Facility ID#(if applicable) ft. ft
120 Boyd Nelson Rd Pinnacle ft. ft. MAY
Physical Address,City,and Zip ft. ft.
Sung 21:REMARKS DWQIBQG
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 �� /►'V� 11/23/21
6.Is(are)the well(s)OPermanent or Temporary Signature of Certi red 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: EJYes 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 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 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: 225 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100� 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
11.Borehole diameter: 6 (in.) 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) 25 Method of test: sight 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine 12oz completion letion of well construction to the coup health department of the
13b.Disinfection type: Amount: P county P county
where constructed. (
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-2016