GW1-2021-06381_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:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
180 k• 185 ft.
2312
k. ft
NC Well Contractor Certification Number A5.OUTER CASING for multitased wells OR LINER if a ticable
Raymond Brown well Company, Inc FROM TO DIAMETER; THICKNESS MATERIAL
Company Name 0 k 121 ft 6.114 j 1 ' I sdr21 pvc
prSp202100198 16.INNER CASING OR zvBING 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): fL ft in.
17.SCREEN
Water Supply Well:
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public k. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft to
Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT
IITI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft bentonite pour
Monitoring DRecovery ft ft cement truck
Injection Well: k ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL`PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
1 Aquifer Test DStormwater Drainage ft ft
Experimental Technology ®ISubsidence Control k. ft
Geothermal(Closed Loop) [2Traeer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HcatingtCooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soiltrock rain size,etc
0 ft. 56 ft soil
4.Date Well(s)Completed:5/3/2021 WellID# 56 k 93 ft soil/sandrock t
So.Well Location: 93 k 465 ft blue ranite 2�:�Le�*�
Ricky Joyce k. ft
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. S 111�
174 Reely Cook Rd. _ql;n;
Physical Address,City,and Zip k. IL le 'J
Surry 21.REMARKS
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,C (cation:
N W _ I�. 5/4/2021
6.Is(are)the well(s)(IPermanent or Temporary Signature ofCertifie—cTWell 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: E3Yes 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-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: 465 (ft-) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2Qa 100D construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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) 2 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: 24Oz completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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