_Well Construction - GW1_20230327 (58)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Bulllns 14.WATER ZONES qdd
Well Contractor Name FROM TO DESCRIPTION
4538 178 ft. 180 it
203 it, 204 ft.
NC Well Contractor Certification Number 15,'OUTER CASING for multi cased wells OR LINER if a' livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICIavEss MATERIAL
Company Name 0 ft. B1 ft. 61/4 1n- 1 dr2i pvc
E H W P2112-012 16.INNER CASING OR TUBING ieothermal 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 IOMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) !X' Residential Water Supply(single) ft. ft.
Industrial/Commercial IOResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. P8 ft. Bentonite Pour
Monitoring DRecovery ft. ft.
Injection Well: rt. ft.
Aquifer Recharge Groundwater Remediation
.19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery I�Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EIStormwater Drainage ft. ft.
Experimental Technology IDSubsidence Control ft. It
Geothermal(Closed Loop) iTracer 20:DRILLING.LOG attach additional sheets if necessary)."'
FROM TO DESCRIPTION color,hardness,soii/rock e, rain s eta)
Geothermal(Heating/Cooling Return) r ' Other(explain under#21 Remarks)
0 ft. 50 ft Soil
4.Date Well(s)Completed:5-24-22 Well ID# 50 rt. 245 ft. Blue Granite
5a.Well Location: ft. ft. R, .
Powell &Associates ft. rt. ,` !L--",..,'ti;_
Facility/Owner Name Facility ID#(if applicable)
rt. ft
1708 Estes Rd ft. ft.
Physical Address,City,and Zip ft ft lnfi:4 n r.'.^'l
Rockingham ,:.21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilong is sufficient) 22.Certification:
N W 5-24-22
6.Is(are)the well(s)oPermanent or fOTemporary Signature ofC�Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or MNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis 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 ofwells construction details. You may also attach additional pages ifnecessary.
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 ifdi{jerent(example-3 200'and 2@I000 construction to the following:
10.Static water level below top of casing:40 (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 Infection 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) 30 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: 14oz 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