_Well Construction - GW1_20230327 (23)

�Frint Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Bulllns 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
214 ft- 215 ft.
4538 ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased`wells OR LINER if a, ucable:
Raymond Brown well Company, Inc FROM TO DIAMETERr THICKNESS MATERIAL
0 ft 126 ft 6114 In' I sd21 pvc
Company Name
353426 '16.INNER CASING OR TUBING(geothermal dosed-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.
3.Well Use(check well use): ft. ft. in.
17.SCREEN:_
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) &GROUT r
Irri atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 24 ft. eentonite Pour
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge I0Groundwater Remediation
19:SAND/GRAVEL PACK if applicable)
`
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology IOSubsidence Control ft. ft.
Geothermal(Closed Loop) I©ITracer 20.DRILLING LOG attach additional sheets if necessary)
RFROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.
Geothermal(Heating/Cooling Return) 4 Other(explain under#21 Remarks)
0 ft. 60 ft• Soil
4.Date Well(s)Completed:5/5/22 Well ID# 60 ft. 120 ft* Sand Rock
5a.Well Location: 120 ft. 265 ft, Blue Granite
Kale&Jennifer Gaston
Facility/Owner Name Facility ID#(if applicable) ft. ft. ` r'"'" a ^° ?^-•
Woodlee Drive Lot B ft. ft. MAR 2 1 2023
Physical Address,City,and Zip ft. ft.
i
Davie 21.REMARKS
Vio ` JV,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
N W �� 5/5/22
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certifi d 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 �XX No 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 921 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: 265 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 35 (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) 35 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit ione copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: taoz 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 1 Revised 2-22-2016