GW1-2021-06319_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
390 ft- 391 fL
2312
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a Qcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 It' 120 ft' 6.1/4 in sdr21 pvc
311720 16.INNER CASING OR TUBING eotbermal 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 []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•
:)Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft fi- bentonite pour
Monitoring DRecovery ft. 20 ft. cement truck
Injection Well: ft. fL
Aquifer Recharge [DGroundwater Remediation 19:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. fL
Experimental Technology DSubsidence Control ft. fL
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain six etc
Geothermal(Heating/Cooling Coolin Return) (- Other(explain under#21 Remarks)
0 ft. 45 ft. soil
4.Date Well(s)Completed: 5/7/2021 Well ID# ft. ft. soil/sandrock
Sa.Well Location: 45 ft. 1005 ft- bluegranite ,�a
Corey Barnette ft. ft.
Facility/Owner Name Facility ID#(if applicable) It. ft.
763 Eagle Mills Rd. ft. fLo•�
,Physical Address City, `y ty,and Zip ft. ft.
Jos
Iredell -.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) 22.Talon.'
N W ,C . ( � - 5/24/2021
6.Is(are)the well(s)oPermanent or ©ITemporary 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: [3Yes 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 921 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 I 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: 1005 ft
P ( ) 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:65 (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 Iniection 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: j
(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&Iniection 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: 12oz completion of well construction to the county health department of the county
where constructed. F
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016