GW1-2023-02419_Well Construction - GW1_20230404

11 Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris BullinS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312 1e0 ft. 162 ft
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi�ased'wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER I THICKNESS MATE RiAi.
Company Name 0 ft 147 ft. 61/4 I iO• I d,21 pvc
FRWL.2�2�01600 "36.INNER CASING OR TUBING 'eothermhil closed-ldo -
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Couuty,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 DMunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Cement Truck
Monitoring i Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
+;19:SAND/GRAVEL PACK if applicable)
`
Aquifer Storage and Recovery QlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft, ft
Experimental Technology '[)Subsidence Control ft. ft
Geothermal(Closed Loop) I©ITracer 20.DRILLING LOG attach additional sheets if necessa
RGeothermal
(Heating/Cooling Return) MI Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sailfrock type rain size,etc.)
0 ft. 63 ft Soil
4.Date Well(s)Completed:3/2/22 Well ID# 53 ft. 140 ft Sand Rock
5a.Well Location: 140 ft. 525 ft- Granite
Natalie Baro ft. ft
Facility/Owner Name Facility ID#(if applicable)
it. ft _.- y.r.z 1 e, 4—�1
734 Maranon Way. fr. ft APR 4 2023
Physical Address,City,and Zip ft. ft
Surry 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
N W 3/2/22
6.Is(are)the well(s)OPermanent or ©ITemporary 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: QYes or X 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 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: 525 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3@200'and 2@100 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 276994636
13a.Yield(gpm) 2 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: 25oz 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