GW1-2022-04757_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bullins 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
280 k. ft.
2312 o k. I o ft.
NC Well Contractor Certification Number 15.OUTER CASING far multi cased wells OR LINER if'a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICIQVESS MATERIAL
Company Name
0 ft, yq fi- 61/4 1 ' sd21 pvc
21-09-W N H R-08185 `16:INNER CASING OR TUBING eetnermalelosed-iaa
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): k. ft. in.
17.SCREEN
Water Supply Well: FROM_ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public k. k. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) k• ft. in:
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Cement Pour
Monitoring DRecovery ft. tL
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
rIlAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology E3 Subsidence Control
Geothermal(Closed Loop) U3Tracer 20.DRILLING LOG'attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilfrock e, rain size,etc.
Geothermal(Heating/Cooling Coolin Return) Mother(explain under#21 Remarks)
0 tt• 20 1L Red Clay
4.Date Well(s)Completed:4/1/22 Well ID# 20 k. 49 & Sand Rock
5a.Well Location: 49 k 325 ft- Blue Granite
Derrick Holbrook k. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
5838 Frieden Church Rd k• ft
Physical Address,City,and Zip ft. ft kdowww laroccomV
UW—
Guilford 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 cj,," 4/1/22
6.Is(are)the well(s)OPermanent or OTemporary 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 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#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 to provide additional well site details or well
construction,only I GWA 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 2Q100� construction to the following:
10.Static water level below top of casing: 10 (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) 40 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: 8oz completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016