_Well Construction - GW1_20230327 (24)

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Phillip BUIIIIIS 14.WATER ZONES 1:='
Well Contractor Name FROM TO DESCRIPTION
268 ft• 269 ft.
4538 302 ft* 303 ft.
NC Well Contractor Certification Number 15:OUTER CASING for multi cased wells OR LINER if a Rcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL '
0 ft- 110 ft- 61/4 in• sd,21 pvc
Company Name 35342� :"16.INNER CASING OR TUBING(geothermal 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): ft. ft. in.
Water Supply Well: ,17.SCREEN r ,
FROM TO DIAMETER SLOT SIZE THICKNESS -MATERIAL
Agricultural OMunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) GROUT
1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 30 ft. Bentonite Pour
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer RechargeGroundwater Remediation
i�19 SAND/GRAVEL PACK if applicable)_
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. to
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiifrock e, rain size,etc.)
Geothermal(Heating/CoolingReturn) I Other(explain under 421 Remarks)
p ft. 80 ft• Sail
4.Date Well(s)Completed:5/6/22 Well ID# 80 ft. 105 ft.
Sand Rock
5a.Well Location: 705 ft. 325 ft- Blue Granite
Kale&Jennifer Gaston ft. ft. _ �r
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Woodlee Drive Lot A ft. ft A D
Physical Address,City,and Zip ft. ft.
Davie -''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 5/6/22
6.Is(are)the well(s)oPermanent or I©ITemporary 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: r1Yes or �XQINo 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 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: 325 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 55 (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 Injection 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:
(Le.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) 25 Method of test: sight 24c.For Water Supply&Injection 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: 18oz 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
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