GW1-2021-06410_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
ft•2313 unknown fL i
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER ifa livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 72 ft. 6.1/4 j in• sdr21 PVC
ehw 2O 1 O-OOH :16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: p FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) tt. in,;
Industrial/Commercial Residential Water Supply(shared)
18:GROUT
`hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 23 R- bentonite pour
Monitoring C-Recovery ft. ft* cement truck
Injection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL:PACK if applies I ble
Aquifer Storage and Recovery ID Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft• ft
I Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soitfmck type,gnin size,etc.
0 ft. fL soil
4.Date Well(s)Completed:3/25/2021 Well ID# 0 et' 60 ft. soil/sandrock
5a.Well Location: 80 ft. 725 ft bluegranite
Jeff Harris ft. ft. ic-
Facility/Owner Name Facility ID#(if applicable) ft. ft. x� ���"yam t
131 M&M Ln ft. ft. �Z
Physical Address,City,and Zip ft. ft
Rockingham 2I.REMARKS r�G
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 `T-- C - �WV`�{ 1 - 5/26/2021
6.Is(are)the well(s)oPermanent or E3Temporary 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: E]Yes 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-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: 725 (ft-) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 100 (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: 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:
(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) 1 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: 1 3/4 completion of well construction to Ithe 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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