_Well Construction - GW1_20230327 (28)

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W-16 ,CONSTRUCTION RECORD(GW-1) For Internal Use Only-
VI.Well Contractor Information:
Phillip Bullins 14.-WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 292 ft- 293 ft.
4538 o ft. 0 ft.
NC Well Contractor Certification Number 15:OUTER CASING for muld4ased wells OR LINE&if a licable .
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft 143 ft. 61/4 in. sd21 pvc 77—
Company Name A&'INNER CASING OR TUBING, eothermal closed400
2.Well Construction Permit#• 2021045 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Irariance,'etc.) ft. ft. la
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR MBE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in•'
Geothermal(Heating/Cooling Supply) iX Residential Water Supply(single) ft. ft. in.
_,Industrial/Commercial DResidential Water Supply(shared) ;,15 GROUT
Iirl atien FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 12 ft. Bentonite Pour
Monitoring EIRecovery ft. it. Hole Plug
Injection Well:
ft. ft.
Aquifer Recharge IOGroundwater Remediation
19:'SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery fDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. fL
Experimental Technology DSubsidence Control ft. fL
Geothermal(Closed Loop) ©ITracer 20:DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 1170ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness•soilfrock type rain size,etc.)
0 ft. 80 ft. Soil
4.Date Well(s)Completed:5/10/22 Well ID# 80 ft. 130 % Sand Rock
5a.Well Location: 130 ft. 325 fL Red Shell I• _ _
Paul Quick ft. ft .- s '«• �
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR 2 I 7
3911 Tanglebrook Rd ft. %
Physical Address,City,and Zip
Forsyth 'Zl REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W ��fJ 'lD 5/10/22
6.Is(are)the well(s)OPermanent or IOTemporary Signature ofCertifieJ Well Contractor Date
By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: QYes or rXINo 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@100) 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:
(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) 10 Method of test- sight 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit I 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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