GW1-2023-02433_Well Construction - GW1_20230404

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bullins 14.WATERZONES
Well Contractor Name FROM TO T DESCRIPTION
2312 390 ft- 392 ft.
ft. IL
,
NC Well Contactor Certification Number 15.OUTER CASING for multi cased wells OR LINER.(if a ticable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 81 ft- 61/4 in' sd2l pvc
Company Name
FRW�202201125 16.INNER CASING ORTURING 'eothermalclosed-loo
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 IDMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
—,Irri ati0n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. chips Pour
Monitoring DRecovery ft. ft.
Injection Well:
rt. rt.
Aquifer Recharge DGroundwater Remediation
1:19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology I0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ; Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,son frock type min size,etc.)
0 ft. 45 ft* Soil
4.Date Wells Completed:6/10/22 Well ID# 45 ft. 74 ft.
()Com p Sand Rock
5a.Well Location: 74 ft. 425 ft•
Granite
Scotty Beck ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft APR v 4 2023
Bryan Rd ft. ft
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 lat/long is sufficient) 22.Certification:
N Wes, 6/10/22
6.Is(are)the well(s)OPermanent or E3Temporary 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: E]Yes or XINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conduction Standards and that a
Ifthis 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 ofthis 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 I 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: 425 (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 rQr 200'and 2Qa 100) construction to the following:
10.Static water level below top of casing:60 (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 Injection Wells: hi 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&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine 13b.Disinfection type: 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