GW1-2021-06404_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
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2313
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER T'IHCKNEss MATERIAL
0 ft. ft. 6.1/4 in. sdr21 pvc
Company Name
ehwp2105'005 16.1NNER CASING OR TUBING eothermal 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. It. In.
3.Well Use(check well use): ft, it. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public fL ft. im
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in;
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Itri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft, bentodite pour
Monitoring pRecovery 0 ft. ft* cement pour
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
:19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) (-' Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock typc rain siz(,etc.)
0 ft. ft. soil
4.Date Well(s)Completed: 7/1/2021 Well ID# 0 ft. ft. soil/sandrock
5a.Well Location: d05 ft. 545 ft- blueg Itanite
Brandon Strader rL pN
Facility/Owner Name Facility ID#(if applicable) ft. fL n
3061 Country Ln
Physical Addres and Z ft, ft
Reidsville 21.REMARKS
7.;.),� or\,fly
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 -,C 17/8/2021
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: O 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 GWA 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: 545 (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 20100D construction to the following:
10.Static water level below top of casing: 55 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In add Iition to sending the form to the address in 24a
above,also submit one copy of tliislform 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) 7 Method of test: Sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 19 completion of well construction to the county health department of the county
where constructed. E
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016