GW1-2021-06423_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION:
Well Contractor Name
ft. ft. �
3308 ft. rL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER tf a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 82 f4 6.1/4 1O sd121 pvc
Company Name
q '=76.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: .�SZ 1 FROM I 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.
1
Water Supply Well: ;.F�R.SCREEN
TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
"I Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) All.GROUT
7_11rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft* bentonite pour
Monitoring D Recovery 0 ft. it. cement pour
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19:SAND/GRAVEL PACK'if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [Stormwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,wit/mck type rain size,etc.
0 ft. 15 ft. soil
4.Date Well(s)Completed:6/30/21 Well ID# 15 ft. 75 tL soil/sandrock
Sa Well Location: 75 ft. 605 ft- blue r6nite1
Nathen Hagedorn ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft. 5
1639 Brookcove Rd. ft. ft. Q� .%V%(3
Physical Address,City,and Zip ft. ft. �F�j`�Gt',0 l C oC�a011
Stokes 21.REMARKS'
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N w , C � 1 7/23/2021
6.Is(are)the well(s)OPermanent or []Temporary Signature of Certified Well Cmitract6r Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well' [Yes or F.JNo 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 io1he 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 NLJMBER of wells construction details. You may also'attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (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:25 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 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) 8 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: a completion of well construction to the 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