GW1-2021-06399_Well Construction - GW1_20210915

P.,rint F,orr'li�
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 4
i
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 360 ft• 365 ft.
a. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR'LINER if a Iicable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 41 ft.
6.1/4 in.
sdr21 pvc
Company Name
2020-00003381 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-
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in.',
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrt ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite chips pour
Monitoring .Recovery 0 ft. ft cement truck
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology []Subsidence Control ft. ft
Geothermal(Closed Loop) lOTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rocktype, rain siz etc.
p ft. 12 ft. soil
4.Date Well(s)Completed: 11/5/2020 Well ID# 12 ft. 33 ft soil/sandrock
5a.Well Location: " ft 405 fL blue ranite
Shane Harman ft. ft
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
Anal
10262 US HWY 64 East Staley ft. ft 1
Physical Address,City,and Zip ft, ft.
Randolph 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.Certification:
N W -A), Q . k� 6/21/2021
6.Is(are)the well(s)IIPermanent or OTemporary Signature fCertified Well Co tractor Date
By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or EJNo 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-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: 405 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (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:
(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) 100 Method of test: Sight 24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to
the address(es) above, also subrhit!one copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 18oz completion of well construction 'to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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