GW1--06738_Well Construction - GW1_20231024

IL Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bullins 14.WATER ZONES .'
We1lContractorName FROM TO DESCRIPTION
2312 N/A ft. ft. I '
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap lieable)
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL •
0 ft. 58 ft. 61/4 in. sdr21 pvc
Company Name
N/A ?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.
'>17:SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IO'Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial IQResidential Water Supply(shared) • 18.GROUT
X Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - --0—R.-—20 ft.—Hole Ploy —Pow
Monitoring (©(Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge D Groundwater Remediation
:;19.SAND/GRAVEL PACK(if applicable) `
Aquifer Storage and Recovery DISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft ,
Experimental Technology IOSubsidence Control ft ft
Geothermal(Closed Loop) DiTracer 20.DRILLING LOG(attach additional sheets if necessary) i ,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) EtOther(explain under#21 Remarks) 0 ft. 20 ft., Red Clay
9-22-23 ft ft -
4.Date Well(s)Completed: Well ID# 20 53 sand Rock ~',z r y'_" -,\
. - ,'--,,,. a.., .r; vd $1.., :,.t.
5a.Well Location:
a ft. 1080 ft. Blue Granite
Pete Denny ft. ft. UCT 2 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1^s` ;^ , _Jr•_M
Intersection of Angell Rd & Neil Rd, Madison ft. ft G k G`
Physical Address,City,and Zip ft. ft.
Rockingham 21.REMARKS /!
County Parcel Identification No.(PIN) Dry Hole f f 6 W e{`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W (/k1 �i e:41 r, 9/22/23
6.Is(are)the well(s)DIPermanent or I❑—(Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: lYes orDNo with 15A NCAC 02C.0100 or 1SA 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
depth below land surface: 1080
9.Total well
(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@200'and 2@100') construction to the following: j ,
N/A
10.Static water level'below top of casing: - (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service iCenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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) 0 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: HTH Amount: lsoz 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 War Resources' Revised 2-22-2016