_Well Construction - GW1_20230327 (70)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Bulllns �-14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 262 ft- P63 ft
4538
312 ft, 313 ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OIL if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fL 38 ft. 1 61/4 in, I sdr2l live
Company Name
3617 16:INNER CASING OR TUBING(geothermal 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: FROME TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft.
_.Industrial/Commercial DResidential Water Supply(shared) 718..GROUT
1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 30 ft. Bentonite' Pour
-.- Monitoring DRecovery ft. ft.
Injection Well:
ft, ft.
Aquifer RechargeGroundwater Remediation
=19r SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fOStormwater Drainage ft. ft
Experimental Technology [ISubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
_ Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
0 ft. P1 ft Soil/Granite
4.Date Well(s)Completed:7/19/22 Well ID# 21 ft. 365 ft- Blue Granite
5a.Well Location: ft. ft,
S
Vincent Rogers ft. ft
Facility/Owner Name Facility ID#(if applicable)
ft. ft MA i Z023
1240 Bolejack Rd ft. ft 1 -_
Physical Address,City,and Zip ft. ft ( 1;; •, ,
Stokes 21:REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W &14? 7/19/22
6.Is(are)the well(s)oPermanent or OTemporary 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: EJYes or )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 ofthe 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 of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelfferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 55 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use••+" 1617 Mail Service Center,Raleigh,NC 276994617
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:
(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) 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: 19Oz 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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