_Well Construction - GW1_20230327 (77)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Bullins 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
145 ft. 150 ft.
4538
0 ft. 0 ft. �
NC Well Contractor Certification Number 15:OUTER CASING for multi�ased'ivells OR LINER if a lieable
Raymond Brown well Company, Inc FROM TO DIAMETER Ta1CIINESs MATERIAL
0 ft- 38 % 1 6114 1°' sd21 pvc
Company Name
'':16.3NNER CASING OR TUBING.(geothermal closed-loop)
3676
2.Well CODStrUCtlOn 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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'X Residential Water Supply(single) ft. ft. in.
-i Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
liTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 25 ft. Bentonite Pour
:)Monitoring D Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [Groundwater Remediation
'i i9.;1SAND/GRAVEL PACK if applicable)
'
Aquifer Storage and Recovery 'lD_ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer :',20.DRILLING LOG attach additional sheets if necessary)
_ FROM TO DESCRIPTION color,hardness,soil/rock e• ram size,etc.)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks)
p ft. 20 ft. Soil
4.Date Well(s)Completed:5/11/22 Well ID# 20 ft. 185 % Blue Granite
5a.Well Location: ft. ft.
Juan Hernandez rt. ft. - -
Facility/Owner Name Facility ID#(if applicable)
1085 Curtis Lane f• ft. MAR 2 i 7073
Physical Address,City,and Zip ft. ft.
Stokes k21.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 5/11/22
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify' that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or IX 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 esplain the nature of the copy of this 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: 185 (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 a200'and 2@100) construction to the following:
10.Static water level below top of casing:35 (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:
(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( pm) 20 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: tooz completion of well construction to the county health department of the county
where constructed.
I �
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016