GW1-2021-06297_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD (GW-1) ti� For Internal Use Only:
1.Well Contractor Information:
Raymond Brown ATER ZONES
OM TO DESCRIPTION
Well Contractor Name `� ' 261 ft 262 ft i
2313 0 �'? o G%fly e. ft
NC Well Contractor Certification Number 'J' CJ
�r;'• 15.OUTER CASING for multi cased'wells OR LIlVER if a licable
Raymond Brown well Company, FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 124 ft- 6.1/4 '"' sdr21 pvc
330571 16.INNER CASING OR TUBING(geothermal closed-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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. in
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_.IITi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• rt• bentonite pour
Monitoring lRecovery 0 ft, 48 ft' cement truck
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
i 19.SAND/GRAVEL PACK if malleable)
Aquifer Storage and Recovery 0Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. tL
Experimental Technology EISubsidence Control ft. I ft.
Geothermal(Closed Loop) IOTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soiUrock a raid size etc.
0 ft. s tt. soil
4.Date Well(s)Completed:4/12/21 Well ID# 9 ff 117 ft' soil/sandrock
5a.Well Location: 117 ft. 525 ft• blue ranite
Kevin Thomas ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
4323 Camp Betty Hastings ft. ft
Physical Address,City,and Zip
Forsyth 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) 22rC-
tion•
N W 5/26/2021
6.Is(are)the well(s)oPermanent or OTemporary 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: E3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 GWA 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: 525 (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@I00) construction to the following:
10.Static water level below top of casing: 39 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 1 (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&Injection Well ' 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: t9oz 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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