_Well Construction - GW1_20230327 (21)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bullins 14.WATER ZONES'; -
Well Contractor Name FRO51 TO DESCRIPTION
2312 200 ft. ft•
ft. ft.NC Well Contractor Certification Number .15:OUTER�CASING for multi cased wells OR-LINER if a Hcable) -
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 f1. 48 ft. 6114 1 1" sd21 pvc
Company Name
2�2�����56. '16.INNER CASING OR TUBING. eothermal 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): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) I&GROUT
�Ilrrijzation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft Hole Plug Pour
Monitoring , Recovery ft, ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
49:SAND/GRAVEL PACK if a 'licable
i Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 3Stormwater Drainage ft. fL
Experimental Technology DSubsidence Control ft. %
Geothermal(Closed Loop) Tracer a20.DRILLING LOG(attach-additional sheets if necessary)
_ Geothermal eating/Cooling Return) ( Other(explain under#21 FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)
Remarks)
0 ft. 20 f1' Red Clay
4.Date Well(s)Completed:6/20/22 Well ID# 20 ft. 43 ft. sand Rock
5a.Well Location: 43 ft. 245 % Blue Wanite
Patriot Farms LLC ft. ft
Facility/Owner Name (^-� j",t Yr,Q,.,'—Facility lDi(if applicable) ft. ft.
1597 Surratt Rd I n ' 2073 ft. ft.
Physical Address,City,and Zip ft. ft.
Davidson "'
?rCG " n31)l :$ ;-121.REMARKS
�;M��,� ='
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification: ,, A
N w C�/y,b W 6�ZO�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: QYes or rXJNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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 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: 245 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Intention 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 276994636
13a.Yield(gpm) 15 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount' 6Oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016