GW1-2021-00618_Well Construction - GW1_20210205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
r
1.Well Contractor Information: j
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
173 ft- 175 ft.
2313
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER i Rcable
Raymond Brown well Company, Inc FROM TO DIAMETER THMESSf a MATERIAL
Company Name 0 ft. 61 ft' 1 6.1/41 in' I Sdr21 I pvc
rw1202002909 .16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: p FROM TO DIAMETER I.TMCKNESS I 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 [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial ORcsidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 25 it• bentontle pour
[ Monitoring C3Rccovery
Injection Well:
Aquifer Recharge r3Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG°attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) EllOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type,gmin size,etc.
0 ft- 40 ft. soil
4.Date Wells Completed: 12/29/2020 Well ID# 40 ft. 55 ft.
p soil/sandl'ock
5a.Well Location: u ft. 205 ft- bluegranite
Cedric Lefebvre
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
TBD Mt Zion Rd
Physical Address,City,and Zip
Surry 21.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: t
N W _ 0-- \� - 01/04/2021
6.Is(are)the well(s)r3Permanent or (�,I' Temporary Signature of Certified Well Contractor I 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: ®Yes or E)No NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain u uu E O 'is 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 ellVV 5 21Q4 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: (;^r,C,-mation ProceS§ft ALINSTRUCTIONSI
DWR Secti
9.Total well depth below land surface: 205 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths l dierent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 45 (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: (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 27699-1636
13a.Yield(gpm) 40 Method of test: Sight 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit jone copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 14 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