_Well Construction - GW1_20230327 (59)

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WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only: � �
r.
1.Well Contractor Information:
Chris Bullins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
250 ft. ft.
2312 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 MATERLAL
Company Name �I 0 ft. 68 ft 61/4 1° sd21 pvc
E flI p�P2 �9-�2 `'16.INNER CASING OR T[JBING eotbermal closed-loo =
2.Well Construction Permit#: V V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: >47.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
-)Geothermal(Heating/Cooling Supply) IOResidential Water Supply(single) ft. ft. i°•
- Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. Hole Plug Plug
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
'_19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL; EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology ID Subsidence Control ft. ft.
Geothermal(Closed Loop) I❑—(Tracer .20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soi0rock e, 'n six etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 20 ft. Red Clay
4.Date Well(s)Completed:4/29/22 Well ID# 20 ft. 63 ft. Sand Rock
5a.Well Location: 83 ft. 265 fr• Blue Granite
Kim Martin ft. ft. _
Facility/Owner Name Facility ID#(if applicable) ft. ft. ra
894 Anglin Mill Rd ft ft
Physical Address,City,and Zip ft. ft.
Rockingham 21.,REMARKS In:.. n lat:
vjr e��'i.i��.3
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 4/29/22
6.Is(are)the Well(s)OPermanent or 1©ITemporary Signature of Certified 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: E]Yes or �X No 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 021 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: 265 (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@I00) construction to the following:
10.Static water level below top of casing: 130 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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:
(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) 50 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: 6oz 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