_Well Construction - GW1_20230327 (71)

IF Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Phillip Bulllns 14.WATER ZONES'
Well Contractor Name FROM TO DESCRIPTION
4538 247 ft- 248 ft.
ft. ft.
NC Well Contractor Certification Number AS.OUTER CASING for multi cased:wells UR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft 1 72 ft- 1 61/4 rn' sd21 pvc
Company Name
3745 '.FROM
CASING OR TUBING eothermal closed-Ioo
2.Well Construction Permit#: 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: 1T:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) ;4&GROUT j.
Irfi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 26 IL Bentonite Four
Monitoring DRecovery ft. fL
Injection Well:
ft. ft.
Aquifer RechargeGroundwater Remediation
:>19:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery P©ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft, ft.
Experimental Technology OSubsidence Control ft. IL
Geothermal(Closed Loop) E3Tracer i:20.DRILLING LOG attach additional sheets if necessa'
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks)
0 ft. 60 ft- Soil
4.Date Well(s)Completed:7/20/22 Well ID# 60 ft. 345 IL Blue Granite
Sa.Well Location: ft. ft. +z y, ••• -
Larry Neal ft. ft 9 7
2 oov
Facility/Owner Name Facility ID#(if applicable) - ft. FL
1060 James Rd ft. ft. ;r;;;;;:;. „;,
Physical Address,City,and Zip
Stokes >r21 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 7/20/22
6.Is(are)the well(s)oPermanent or OTemporary Signature ofCertified 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: E]Yes or X]No with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this 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 of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 345 (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@100D construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 A/fall Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of thisiform 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) 10 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: 17oz completion of well construction to ilhe 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