_Well Construction - GW1_20230327 (29)

JF—TFFint Form "
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Chris Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312 900 ft. ft
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING r&multi�ased wells OR LINER If a licable) -
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 75 ft. 1 61/4 in. I sd21 pvc
Company Name
2021�46 :16.INNER CASING OR TUBING. eotbermal"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.
-r17:SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
:)Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
IndustriaVCommereial DResidential Water Supply(shared) '18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 40 ft. Cement Pour
Monitoring I3Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge IDGroundwater Remediation
,49:SAND/GRAVEL PACK if a licdble
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology (3Subsidence Control ft. ft.
R
eothermal eatinCoolin RetReturn) Other(explain under#21 Remarks)eothermal(Closed Loop) I©ITracer r20.DRILLING LOG attach additiona"heets ifnecessaFROM TO DESCRIPTION(color,hardness,soiUrock e, rain size,etc.)
0 ft. 20 IL Red Clay
4.Date Well(s)Completed:4/19/22 Well ID# 20 ft. 70 ft. Sand Rock
5a.Well Location: 70 ft. 1205 ft. Blue Granite
Kent Fulp ft. ft
e h 9
Facility/Owner Name Facility ID#(if applicable) ft A 4
3653 N Patterson Ave ft. % I
Physical Address,City,and Zip ft. ft. If1w+++:•::wt^� ; q.;p• {, ,
Forsyth '21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
N W 4/19/22
6.Is(are)the well(s)oPermanent or [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: E]Yes or X No with 15A 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 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: 1205 ft
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2@100D construction to the following:
10.Static water level below top of casing:33 (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:
(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) 4 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: 16oz 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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