_Well Construction - GW1_20230327 (35)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4538 147 IlL 148 ft. j
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS hrATERIAI
0 fL 45 ft. 61/4 1° sd2l pvc
Company Name
22-06-W N H R-04314 16.1NNER CASING OR TUBING(eothermal 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IlMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) f8.GROUT
7hriiiation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 lit. 36 ft. Bentonite Pump
Monitoring EIRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK if a licable '
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additionalB sheets if necessa
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,solltrock type,grain size,etc
0 ft. 10 fL Soil
4.Date Well(s)Completed:9/28122 Well ID# 10 ft. 245 ft
Blue Granite
5a.Well Location: ft. ft.
Matt Rowell ft. ft.
Facility/Owner Name Facility ID#(if applicable)
6394 Westview Ct ft. ft. MAR 2 i 9
Physical Address,City,and Zip ft. ft.
Guilford 21.REMARKs • `,- - _ :;�: i:::
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 P,�(.ti.�� '6 t. 9/28/22
6.Is(are)the well(s)OPermanent or IOTemporary Signature of ertified 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• [3Yes or nNo with 1SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown well construction information and erplain 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 oc 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: 245 (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@100) construction to the following:
10.Static water level below top of casing:44 (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 Inlection 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) 8 Method of test: sight 24c.For Water Supply&Inlection 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: 160z 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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