GW1-2023-02435_Well Construction - GW1_20230404

i 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 225
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells.OR LINER if a 6cable
Raymond Brown well Company, Inc FROM TO DIAMETER; THICKINESS MATERIAL
0 ft. 131 ft- 1 61/4 in. sdr2l pvc
Company Name
PRW L202 1 02359 FR INNER CASING OR TUBING` eothermal closed-ES
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) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) I&GROUT.
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
Monitoring ! Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge I3Groundwater Remediation
-�19.SAND/GRAVEL-PACK if applicable)
Aquifer Storage and Recovery f�Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©I Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft, ft.
Geothermal(Closed Loop) OTracer 20.DRILLING.LOG attach additional sheets if necessary)'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,s;itlrecktype min size,etc.)
0 ft. 60 IL Red Clay
4.Date Wells Completed:6/20/22 Well ID# 60 ft' 126 ft- Sand Rock _
5a.Well Location: 126 ft, 285 ft. Blue Granite
Mayberry Marketing Group LLC ft. ft.
APR 2023
Facility/Owner Name Facility ID#(if applicable) ft, ft. -
3999 E Pine St ft. ft.
Physical Address,City,and Zip ft. ft W '
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 W 6/20/22
6.Is(are)the well(s)OPermanent or ©ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rJYes or )No with I5A 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: 285 (ft) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 30 (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 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) 30 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: 6Oz 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
I