GW1-2021-06429_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name y
t
2313 tas ft• tst f
ft. ft.
NC Well Contractor Certification Number '--,15.OUTER CASING for multitased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL.
0 ft 80 ft- 6.1/4 1 in, sdr21 pvc
Company Name 16 INNER CASING OR TUBING(geothermal thermal 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.
17.
Water Supply Well: FROM SCREENTO DIAMETER :' SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Pabhc ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft in
Industrial/Commercial Residential Water Supply(shared) 18.'GROUT
hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft. bentonite pour
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge K Groundwater Remediation 19.SAND/GRAVEL PAC if applicable)
ft. t
'
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Geothermal(Heating/Cooling Return) E3Other(explain under#21 Remarks)
0 ft. 70 tt• soil
4.Date Well(s)Completed:4/26/2021 Well ID# ft. ft soil/sandrock
5a.Well Location: '° ft• 225 ft blue eanite
Eric Sink ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1175 Milsap Rd ft. ft
Physical Address,City,and Zip ft. fL 2
Stokes .21.REMARKS'
County Parcel Identification No.(PIN) ;'r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. rtifteation:
N W _` - 4/29/2021
6.Is(are)the well(s)13Permanent or ®ITemporary 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: OYes 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 retard has been provided toithe 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: 225 (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 2@100) construction to the following:
10.Static water level below top of casing: 50 (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) 10 Method of test: Sight 24c.For Water Supply Bt Iniection Wells: In addition to sending the form to
the address(es) above, also subnritl one copy of this form within 30 days of
13b.Disinfection type: Hth Amount' 12 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 Resources Revised 2-22-2016
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