GW1-2022-04746_Well Construction - GW1_20220511

Prin.t Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312 ft- 500 ft.
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi=dwells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER,' THICKNESS MATERIAL
0 ft. 90 ft. 61/4 in. sd,21 pvc
Company Name
2�21051 =16.INNER CASING OR TUBING eotherioal 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): IL ft In.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft. Hole Plug Pour
Monitoring ElRecovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
'
Aquifer Storage and Recovery IOSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soWrack a rain size,etc
0 ft. 20 fL Red Clay
4.Date Well(s)Completed:4/2/22 Well ID# 20 ft. 85 ft. Sand Rock
5a.Well Location: es ft. 645 ft Blue Granite
Damian Belk ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. i
2432 Spicewood Dr ft. ft
Physical Address,City,and Zip ft. ft
Forsyth 21-REMARKS LIM
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 `t 66eyz 4/2/22
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified 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: ®Yes or ONo with I5A NCAC 02C.0100 or 15A NCAC 02C.0100 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 jto provide additional well site details or well
construction,only I 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: 645 (ft.) 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:46 (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) 10 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: 16oz completion of well construction tol the county health department of the county
where constructed. II
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016