GW1-2022-04643_Well Construction - GW1_20220512

f
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Bullins 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4538 721 ft• 722 ft.
ft, 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. 30 ft. 61/4 f 11° sdr2l pvc
Company Name
PRWL2�2103�10 .16.INNER CASING OR TUBING eothermal dosed400
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I 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 []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) fL ft.
I Industrial/Commercial 1IResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 28 tt. Chips Pour
Monitoring ElRecovery
Injection Well:
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach addition at sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks)
0 ft. 10 ft. Soil
4.Date Well s)Completed: 1 1/23/2j Well EN 10 ft. 745 ft
( p Blue Granite
5a.Well Location: ft. ft.
Diane Dezern ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
RECEI
720 Shoals Rd ft. ft.
Physical Address,City,and Zip ft
Surry 21.REMARKS
V
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N `'it � 11/23/21
��u1,li.� l�c�ll'.y►>JS
6.Is(are)the well(s)OPermanent or ®ITemporary Signature ofCert�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: E3Yes 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-I 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: 745 (ft-) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths f different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 100 (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:
.e.auger,rotary, construction to the following:
('r ,g tary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service I Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Method of test: sight 24c.For Water Supply&Injection 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: 19oz completion of well construction to`Ithe county health department of the county
where constructed.
h
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016