GW1-2021-06384_Well Construction - GW1_20210915

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 147 ft- 150 ft.
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETERI THICKNESS MATERIAL
0 ft. 50 R' 6.1/4 1. sdr21 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: prw1202004517 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.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTStZE THICKNESS MATERIAL
Agricultural EIMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1i ri atlon FROM TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. bentonite chips pour
Monitoring Recovery
Injection Well:
Aquifer Recharge []Groundwater Remediation ft.
SAND/GRAVEL PACK if a"licable
Aquifer Storage and Recovery 0Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test I0Stormwater Drainage R. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/mck e, rain size,etc.
-Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks)
0 ft. 30 ft. soil
4.Date Wells Completed:6/1/21 Well ID# 30 ft 45 it
p soil/saridrock
5a.Well Location: 05 ft. 165 ft. blue ranite
Charlie Thompson ft• ft. m�•. Eta
Facility/Owner Name Facility ID#(if applicable) ft. ft. 4e�
464 Mt Pleasent Rd ft. ft. 4t.
Physical Address,City,and Zip ft. ft. e C
Surry 21.REMARKS 00
�l, J s
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.Cer fication•
N W 6/3/21
6.Is(are)the well(s)0 Permanent 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: E]Yes or E)No with 15A NCAC 02C.0100 or 15A NCA602C.0100 Well Construction Standards and that a
Ifthis 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: 185 M-) 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 2Q100� construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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 Iform 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,Un I derground 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: 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 Resources If Revised 2-22-2016
6
' I I