_Well Construction - GW1_20230327 (66)

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
Chris BulllnS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2312
690 ft• 691 ft.
,
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 hIATERIAI.
66 pvc0 f
Company Name
3660 •16.INNER CASING OR TUBING eottiermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable i ell construction permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: A7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(fleating/Cooling Supply) `Residential Water Supply(single) ft. ft. in•
industrial/Commercial Residential Water Supply(shared) 18.GROUT
Agricultural
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. chips Pour
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer RechargeGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) I©ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardum soil/rock type, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 38 ft. Soil
4.Date Well(s)Completed:4/13/22 Well ID# 36 ft. 60 ft. Sand Rock
5a.Well Location: ea ft. 705 ft. Granite —^
Tim Flinchum fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. s AR O r
1023 Hunter Trail ft. ft
Physical Address,City,and Zip ft. ft. C r `.� �-, •_ ) t ..
Stokes 21.REMARKS
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 �„� 4/13122
6.Is(are)the well(s)OPermanent or I Temporary 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: DYes or X No with ISA 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 retard 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: 705 (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@100D construction to the following:
10.Static water level below top of casing: 70 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 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) 2 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: 20oz 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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