GW1-2021-06401_Well Construction - GW1_20210915

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I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES `
FROM TO DESCRIPTION
Well Contractor Name
2313 sos It- sos ft. ¢
ft. I ft. k
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 THICKNESS MATERIAL
0 ft' s1 ft• 6.1/4 in sdr21 pvc
Company Name
ehwp2004-017 16.INNER CASING OR TUBING(geothermal dosed400
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 [3Municipal/Public ft. ft. iW
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 I'L 20 ft- bentonite pour
Monitoring DRecovery ft. ft* cement truck
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 1730ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc.)
0 ft• a ft. soil
4.Date Well(s)Completed:5/13/2021 Well ID# 8 ft 80 ft' soil/sandrock
5a.Well Location: B0 ft. 345 ft- blue �anite
Jennifer Bentiz ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft
515 Combs Rd
Physical Address,City,and Zip ft. ft. a�Z1
Rockingham 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.C •Ica I n:
N W 7- 1 t . 5/24/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes 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#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 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: 345 (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 1@100') construction to the following:
10.Static water level below top of casing:49 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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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) 15 Method of test: Sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subniit'one copy of this form within 30 days of
13b.Disinfection type: Hth Amount- 16oz completion of well construction t.o the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016