_Well Construction - GW1_20230327 (83)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Phillip Bulllns 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
674 ft- 675 ft.
4538
ft. ft. j
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 MATERIAL
0 ft. 80 ft. 6114 in sd21 Pvc
Company Name
3356 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural I©IMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
—' Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 23 ft. Bentonite Pour
Monitoring r Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACE11iENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer =20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) F Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 R• 40 ft Soil
4.Date Well(s)Completed:5/13/22 Well ID# 40 fit. 705 fit. Blue Granite
ft. ft.
5a.Well Location:
Duane Hicks ft. ft. ^ ,to
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1177 John Joyce Rd ft. ft
Physical Address,City,and Zip ft ft.
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 5/13/22
6.Is(are)the well(s)oPermanent or OTemporary Signature ofCertifi d 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: ]Yes or XONo 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 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: 705 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths irdii ferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 95 (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) 2.5 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: 21oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016