GW1-2021-06318_Well Construction - GW1_20210915

-"fin.'.
;Pr�int Ford, �'
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION f
Well Contractor Name
298 ft- 299
2313 ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THCKNESS MATERIAL
0 ft- 43 rt. 6.1/4 in. sdr21 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 21-04-wn h r-03735 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. tt. in.
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Water Supply Well: FROM SCREEN
WaterTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural EIMunicipaVPublic ft. ft. in•'
Geothermal(Heating/Cooling Supply) ROResidential Water Supply(single) ft ft in.
IndustriaVCommercial DResidential Water Supply(shared) 1S.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R. ft. bentonite chips pour
Monitoring E3Recovery ft. 22 ft' cement truck
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVELPACK if applicable)
rm%Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00dier(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
0 ft. 12 ft. soil
4.Date Well(s)Completed: 5/25/21 Well ID# 12 ft. 32 rt. soil/sa'ndrock
5a.Well Location: 32ft. azs ft• blue granite
Lee Gordon ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4918 Oldway Rd fc. ft �� r�C'
Physical Address,City,and Zip ft. ft
Guilford 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W `�. ' 6/3/21
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: MYes 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 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 GW-I 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: 425 (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:32 (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: 6 m.
(� ) 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
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13a.Yield(gpm) 2 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: t7 completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources) Revised 2-22-2016
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