_Well Construction - GW1_20230327 (78)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris BUIIins -14.WATER ZONES'
Well Contractor Name FROM TO DESCRIPTION
350 ft. ft
2312 e. ".
NC Well Contractor Certification Number 15:OUTER CASING for multi cased wells OR LINER if a Iicable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. IO ft. 1 61/4 i°' sdr2l pvc
Company Name
3672 '16.INNER CASING'OR TUBING(geothermal dosed-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. i°•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN'.
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.'GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19:SAND/GRAVEL PACK if a Iicable
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (D Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .20.DRILLING LOG attach additional sheets if necesse ;
_ FROM TO DESCRIPTION(color,hardness,soiVmek e, la size,etc.)
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks)
0 fi• 20 ft. Red Clay
4.Date Well(s)Completed:5/30/22 Well ID# 20 ft. 65 ft. Sand Rock
5a.Well Location: es ft. 365 ft. Blue Granite 1- ,
Tim &Ginger Murray ft. rt. °` � `.•_ i
Facility/Owner Name Facility ID#(if applicable) ft. ft MAR -2 tr
1110 Agusta Hicks ft. ft.
Physical Address,City,and Zip ft. fL it is ii;.. ;'^Z.'':`; •_ ..�: !,(};!
Stokes
'2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latAong is sufficient) 22.Certification:
N W �' t ,� 5/30/22
6.Is(are)the well(s)oPermanent or QlTemporary 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: OYes or E)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 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: 385 (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@100) 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 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) 40 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: 16oz 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