GW1-2021-06269_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only: I
1.Well Contractor Information:
i
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
348 ft- 350 ft.
2312
ft. ft.
i
NC Well Contractor Certification Number 15.OUTER CASING for FEW-cased wells OR LINER if a Qcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 1 62 ft 1 6.1/4 1° sdr21 cALV
Company Name
4556weIIn21 '16.INNERCASINGORTUBING 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.
117.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared) _]Ss GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite,chips pour
Monitoring C Recovery 0 ft. ft. cement truck
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/mck a rain size,etc.
ft. 20 ft. soil
4.Date Well(s)Completed: 5/21/21 Well ID# 20 ft. 57 ft. soil/sandrock
5a.Well Location: n ft. 105 ft- bluegranite
3705 Russell Rd. ft. ft
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Donald Braxton ft. ft.
Physical Address,City,and Zip ft. ft
Alamance 21.REMARKS
v(11
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ott'3 O'600
(ifwell field,one lat/long is sufficient) 22.Certification: I
N W f-- 0_ ` l - 6/11/2021
6.Is(are)the well(S)j3Permanent or ®ITemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an exisAng well: E)Yes or ONo with 15A 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 tolhe 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: 105 (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:26 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service tenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (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&Infection 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: 18 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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