GW1-2023-02430_Well Construction - GW1_20230404

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
Phillip Bulllns =14.WATER ZONES tr a
Well Contractor Name FROM TO DESCRIPTION
4538 122 ft- 123 ft.
ft. rt.
NC Well Contractor Certification Number "15-OUTER CASING for mulfi cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 90 IL 6114 1° sd,21 pvc
Company Name
PRW L.2021 01 840 "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 DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) !X Residential Water Supply(single) ft. ft. in.
:)Industrial/commercial DResidential Water Supply(shared) ;,18.GROUT .
�Ilrriization FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. © ft. nr7e /"
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge IOGroundwater Remediation
19J•SAND/GRAVEL,PACK if applicable)
Aquifer Storage and Recovery I3ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test I3Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary),. -
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type rain size,etc.)
0 ft. 40 ft- Soil
4.Date Well(s)Completed: 11/23/21 Well ID# 40 ft. 85 ft. Soil/Sand Rock
5a.Well Location: as ft. 185 ft- Blue Granite
William Lewis ft. ft • ' i .i'
Facility/Owner Name Facility ID#(if applicable) ft. ft. APR A D i z1
t.
142 Lewis Acres Ln H. ft
Physical Address,City,and Zip ft. ft. r,ls ;• ;.;, .-.,
Surry K21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W 11/23/21
6.Is(are)the well(s)OPermanent or OTemporary Signature ofCerti red Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or )No with 15A NCAC 02C.0100 or ISA 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: 185 (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:20 (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) 75 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: taoz 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
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