GW1-2022-04758_Well Construction - GW1_20220511

Print Form RES
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
s
Phillip Bulllns 14.:WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
403 k. 404 ft.
4538 k. ft. `
NC Well Contractor Certification Number 15.OUTER CASING for mdlti cased`wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESSI MATERIAL
0 k. ? ft- 6 1/4 ln• sdr21 pvc
Company Name
21-01-WRH R-00485 16 INNER CASING OR TUBING eothermal closed-loo
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 E)Municipal/Public it. ft. In.! I _+
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) k. ft rn
Industrial/Commercial E3Residential Water Supply(shared) 18?:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 k. ? ft
Monitoring 3Recovery ft. ft
Injection Well: ft ft
Aquifer Recharge E3Groundwater Remediation
19.'SANDlGRAVEL PACK'if a ticable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage k. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach eddttional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rocka is s' etc
285 k• 425 ft, Blue Granite
4.Date Well(s)Completed:4/25/22 Well ID# ft. ft
5a.Well Location: k. ft
Jason Wood ft. ft
Facility/Owner Name Facility ID#(if applicable) k. ft
RECEIVE
3801 Lilly Farm Rd k. ft
Physical Address,City,and Zip ft. 1t
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 P� 4/25/22
6.Is(are)the well(s)OPermanent or Temporary Signature ofCerti ed Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 19Yes or No with 15A NCAC 02C.0100 or 15A NCAC 01C.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 to provide additional well site details or well
construction,only I 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: 425 M-) 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 2@100) construction to the following:
10.Static water level below top of casing:66 00 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) 35 Method of test: sight 24c.For Water Supply&Infection Wells: In addition to sending the form to
n the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I'd Amount: 71 Z7 Z completion of well construction to the county health department of the county
where constructed. f
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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