GW1-2021-06274_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
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Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
170 ft• 171 ft.
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2313
tt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for molti-cased Wells OR LINER if a'"licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fL S7 ft. 6.1/4 1 in. sdr21 pvc
Company Name '
33017$ '16.INNER CASING OR TUBING eothermal'closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MA rFR7Ar.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): tt. tt. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural i)MunicipaUPublic fL ft. in.i
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. fL in.
Industrial/Commercial DResidential Water Supply(shared) 98.GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL bentoni(e pour
:]Monitoring DRecovery ft. ft' cement truck
Injection Well:
ft. fL
Aquifer Recharge OGroundwater Remediation
19 SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence 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 soiUmck e,grain size,etc.
0 ft. 12 fL SOII
4.Date Well(s)Completed:4/14/2021 Well ID# 12 ft. 79 Tt. soil/sandrock
5a.Well Location: 79 ft. 500 ft• blue ranite
Scott Hall ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. fL
2803 Peak Creek Ch Rd. ft. I It.
Physical
Address,City,and Zip ft. ft. S F P
2021
21::REMARKS
r ormation Processin lJ
nit
County Parcel Identification No.(PIN)
sclion
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N `''t _ 5/11/2021
6.Is(are)the well(s)oPermanent or [)Temporary Signature of Certified ell 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: []Yes or E)No 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 to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional welldetails:
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: 500 (fir-) 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@100D construction to the following:
10.Static water level below top of casing: 5 (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) 3 Method of test: Sight 24c.For Water Supply&Iniecti n 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: 20 oz completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016
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