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Home My WebLink AboutGW1-2021-06388_Well Construction - GW1_20210915 Print Porte WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Raymond Brown 14.WATER:ZONES Well Contractor Name FROM TO DESCRIPTION 2313 482 ft• 483 % e. rt. NC Well Contractor Certification Number 15.OUTER CASING for multi-cased�wells OR LINER if a llcable Raymond Brown well Company, Inc FROM �50 O DIAMETER THICKNESS MATERIAL Company Name 0 ft. ft 6.1/4 j i° sdr21 pvc prw1202100196 46.INNER CASING OR TusING eothermal closed-loop) 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. 1n. 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. in. Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL fL in. Industrial/Commercial Residential Water Supply(shared) l8.'GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft. 24 IL bentonite pour Monitoring pRecovery ft. fL cement truck Injection Well: ft. fL Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable) Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD Aquifer Test E3Stormwater Drainage ft. fL Experimental Technology Subsidence Control ft. fL Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets H necessa " Geothermal eatin Coolie Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltruck type,grain size,etc 0 ft- 40 ft soil 4.Date Well(s)Completed:4/22/2021 Well ID# 40 ft. 45 ft. soil/sandrock 5a.Well Location: .s ft. 525 ft blue granite Travis Boyd ft. fL r I �- Facility/Owner Name Facility ID#(if applicable) ft. fL 1416 Old Rockford Rd. ft. fL Physical Address,City,and Zip ft. ft. Surry 21.REMARKS n1 L 'JFt Se i County Parcel Identification No.(PIN) CT.OrI 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: N w L. C, Al�" 5/3/2021 6.Is(are)the well(s)13Permanent 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: 13Yes 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: 525 (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 2Qa 100) construction to the following: 10.Static water level below top of casing: 85 (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: (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) 9 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: 18 completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016 9 Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well# Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT >> USGS Local# Page 1 of 4 VDH HDIN# VDH PWSID# *Indicates required field or section **Indicates required field or section,if applicable 1.Contact Information* Contact: Name Address Phone Owner Kyle Batts 3848 Vias Orchard Rd 918-550-1408 Driller Raymond C.Brown, III P.O. Box 337, Danbury, NC 27016 336-593-8239 System Provider 2.Well Location* Physical Address: 3848 Vias Orchard Rd I County/City: Patrick Co./Stuart Va Subdivision Name: Section: Block: Lot: Tax Ma /GPIN#: Latitude: N Longitude: W Datum Source Horizontal: ❑ WGS84 ❑ NAD83 ❑ NAD27 Lat/Long Source(Check One): ❑ Ma ❑ GPS ❑ PPDGPS ❑ Survey ❑ Imagery ❑ WAAS Location Information Collected B Physical Location Description:flat 3.Facility& Use* Type of Facili Check One): Type of Use Check All That Apply): 0 Private 0 Drinking/Domestic Use ❑ Agricultural ❑ Food Processing ❑ Waterworks ❑ Manufacturing ❑ Irrigation ❑ Injection ❑ Observation/Monitoring Well ❑ Geothermal(Cooling/Heating) ❑ Fire Safety ❑Closed ❑Open:❑Returned to Surface ❑Returned to Aquifer 4. Well Construction* Well designation,Name or Number: 170-21-0046 Date Started:4/15/2021 1 Date Completed:4/15/2021 Type Rig: Class Well (Check One): ❑ 1 ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB 0 RIC ❑ IUD ❑ IIIE ❑ IV Construction Type(Check One): 0 New ❑ Existing-Modified: ❑ well ❑ Pump:Date 0 Well Depth:805 ft. Total Hole(borehole)Depth:805 ft. Depth to Bedrock:95 ft. Hole Size(Include reamed zones): 0 inches from 0 to 345 ft. Inches,from to ft. Height of Casing above Land Surface: 1 ft. inches Casing Size(I.D.)and Materials: (below) Total Depth of Casing: 100 ft. 0 inches from 0 to 100 ft. ❑infiued Material pvc Weight per ft.sdr2 or wall thickness in. inches from to ft.❑infilled Material Weight per:ft. or wall thickness in. inches from to ft. ❑infiiled Material Weight per,ft. or wall thickness in. Screen Size&Mesh: inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infiiled Mesh Size Type inches from to ft. ❑infilled Mesh Size Type Water Zones: from to ft. from to ft. from to ft. Gravel Pack: Size: Type: from to ft. I Size: Type: i from to ft. Grout Type: 0 28 Grouting Method: Type of Seal: 0 Bentonite Slurry ❑Neat Cement from t0 ft. 0 Poured from surface ❑pitiess adapter ❑Bentonite pellets/chips❑Concrete ❑Poured through tremmie pipe 0 sanitary seal ❑Neat Cement(6%bentonite) from to ft. ❑Pumped from bottom ward Camera Survey: ❑ Yes ❑ No Date Conducted: Additional Well Construction Form Information Attached: ❑ Yes ❑ No I Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well# Rev)sed 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local# Page 2 of 4 f VDH HDIN# VDH PWSID# Well designation,Name or Number*:170-21-0046 5.Disinfection Well Disinfected: ❑ Yes ® No I Date: 6.Abandonment *When abandoning the well, Sections 1 thru 4 must be completed and/or attach original GW-2 Date Started: Date Completed: Static Water Level(unpum ed level measured): ft. Casing Size(I.D.) and Materials: I Casing Pulled: ❑ Yes ❑ No ❑ Uncased Well Depth of Fill: Ty a and Source of Fill: Grout: From to Type: From to Type: Method of permanently marking location: 7. Pump Test** Static Water Level(unpumped level measured):45 ft. Date: 3/8/2021 1 Method(Check One): ❑ Water Tape ❑ Airline ❑ Transducer ® Other Stabilized measured pumping water level: ft. Date: I Method(Check One): ❑ Top of Well ❑ Top of Casing ❑ Surface Level Test Pump Intake Depth: ft I Stabilized Yield: gpm after hours Natural Flow: ❑ Yes ❑ No Flow Rate 1 gpm Estimated Well Yield: gpm 8.Pump Data** Type: ❑ submersible ❑ Turbine ❑ Shallow Jet ❑ Deep Jet ❑ Other: Motor HP: Production Pump Intake Depth: ft Rated Capacity: gpm at ft TDH 9. Geologic Information Type Logs: Aquifer Test Performed: Water Quality Results Attached:Yes No Comments: Formation Lithology Province Geologic Map Used Elevation For Office Use i Fon GW-2 COMMONWEALTH OF VIRGINIA DEQ Well# Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local# Page 3 of 4 VDH HDIN# VDH PWSID# *Indicates required field or section **Indicates required field or section,if applicable 10.Driller's Log(Use additional sheets if necessary)* Well desi nation Name or Number: 170-21-0046 Depth(feet) Type of Rock or Soil Remarks Drilling Diagram of Well Construction(with Time dimensions) Min. From TO (Color,material,fossils,hardness,etc.) (Water,caving, cavities,etc. 0 80 Soil 80 95 Soil/Sand Rock 95 805 blue granite 11.Certification I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system or those persons directly responsible for gathering the information, the information submitted is to the best of my knowledge and,belief true, accurate, and complete.I am aware that there are significant penalties for submitting false information including the possibility of fine and imprisonment for knowing violations. `Signature*: I - --P)r�UAA j l ` - Date: 4/13/2021 License Number: 2719001181 i 0 i Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well# Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local# Page 4 of 4 VDH HDIN# VDH PWSID# *Indicates required field or section **Indicates required field or section,if applicable Additional Well Construction Data (Use and submit only if additional space is needed) 12.Additional Well Construction Data Well designation,Name or Number: 170-21-0046 Physical Location: 3848 Vias Orchard Rd Date Started:4/15/2021 Date Completed:4/15/2021 Hole Size(Include reamed zones): inches from to ft. inches from to ft inches from to ft. inches from to ft. inches from to ft. inches from to ft. inches from to ft. inches from to ft. inches from to ft. Casing Size .D. and Materials: inches from 0 to 100 ft. ❑infilled Material sdr.21 pvc Weight per ft. or wall thickness in. inches from to ft. ❑infiiied Material Weight per ft. or wall thickness in. inches from to ft. ❑infilled Material Weight per ft. or wall thickness in. inches from to ft. ❑infilled Material Weight per ft. or wall thickness in. inches from to ft. ❑infilled Material Weight per ft. or wall thickness in. inches from to ft. ❑infilled Material Weight per ft. or wall thickness in. inches from to ft. ❑infilled Material Weight per ft. or wall thickness in. inches from to ft. ❑infilled Material Weight per ft. or wall thickness in. inches from to ft. ❑infilled Material Weight per ft. or wall thickness in. inches from to ft. ❑infilled Material Weight per ft. or wall thickness in. inches from to ft. ❑infilled Material Weight per ft. or wall thickness in. Screen Size&Mesh: inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infilled Mesh Size Tvve inches from to ft. ❑infilled Mesh Size Type inches from to ft. ❑infilled Mesh Size Type Water Zones: From 289 to 290 ft. From to ft. From to ft. From to ft. From 765 to 766 ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft. From to ft'. From to ft. Gravel Pack: Size: Type: From to ft. Size: Type: From to ft. Size Type: From to ft. Size: Type: f From to ft. Size: Type: From to ft. Size: Type: From to ft. Grout Type: from 0 to 28 ft. Grouting Method: ❑Bentonite Slurry ❑Neat Cement from to f} ❑Poured from surface ❑Bentonite pellets/chips ❑Concrete ❑Poured through tremmie pipe ❑Neat Cement 6%bentonite from to ft. 0 Pumped from bottom upward i i i E