_Well Construction - GW1_20230327 (22)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Builins 14:WATERZONES
Well Contractor Name FROM TO DESCRIPTION
225 ft. 227 ft I I
4538 I
o ft. B rt. � I
NC Well Contractor Certification Number ;IS.OUTER CASING for multi cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. 33 ft. 6114 in. sdr2l pvc
Company Name
357404 16.INNER CASING OR TUBING eotherinal 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. in.
•17:SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public M ft. ia.
Geothermal(Heating/Cooling Supply) iX Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 11 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 24 ft. Bentonite Pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
'19:'SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer '20:DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/ruck e, rain size,etc.)
BGeothermal(Heatin Coolin Return) i Other(explain under#21 Remarks)
0 ft. 15 ft. Sail
4.Date Well(s)Completed:5/9/22 Well ID# 15 ft. 405 ft. Blue Granite
5a.Well Location: ft. ft.
Jason Martin _ °� ,� ft. ft.
Facility/Owner Name Yacili ^(ifapplicable) ft. ft.
p
Davie Academy Road MAR 2 1 2�2 ft. ft.
Physical Address,City,and Zip c -•Pf- �. �!11 Pt;�C;IV3 l�rr'.t ft, ft.
J
Davie D' 'Qi 50V :,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 5/9/22
6.Is(are)the well(s) (oPermanent or OTemporary Signature ofCertified 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: f©Yes or X)No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis 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: 405 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00 construction to the following:
10.Static water level below top of casing:66 (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) 6 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: Chlorine Amount: ��D completion of well construction fo 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