GW1-2021-06426_Well Construction - GW1_20210915

F � �P-r�lnt Form,
WELL CONSTRUCTION RECORD(GW-1) I For Internal Use Only:
1.Well Contractor Information: j
Raymond Brown 14.WATER ZONES '
Well Contractor Name FROM TO DESCRrPTION
2313 260 ft• 283
350 ft• 352 ft
NC Well Contractor Certification Number i
15.OUTER CASING(for multi-cased wells)OR LINER if a" liceble
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft 101 ft 6.114 in sdr21 pvc
Company Name 16:INNER CASING OR TUBING 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. 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. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fL ft. in.
:Industrial/Commercial Residential Water Supply(shared) I8 GROUT
7 lrri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite pour
:)Monitoring (—Recovery 0 ft. ft. cement pour
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
`19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control k. fL
ar
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soittrock type,grain size,etc.
0 ft. 25 ft. soil !
4.Date Well s)Completed:7/4/2021 Well ED# 25 ft. 94 ft.
( p soil/sandrock
5a.Well Location: 94 ft. 425 ft- blue ranite
Wendy Mason ft. fL
Facility/Owner Name Facility ID#(if applicable)
Frye Rd ft. ft. e
Physical Address,City,and Zip ft. ft.
Stokes 21.REMARKS 13SM,
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: t
N W kv- • 0. �wl�t/�18/16/2021
6.Is(are)the well(s)oPermanent or OTemporary SignatuTCeitified We�ntractor 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: ©Yes or ONo with 15A NCAC 01C.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-I 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: 425 (It-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100D construction to the following:
10.Static water level below top of casing:45 (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: 6 (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 pusty 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) 20 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: 20 completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resource' Revised 2-22-2016