GW1-2021-06386_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 4
1.Well Contractor Information: i
k 4
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
345 ft• 346 ft
2313 i
379 ft- 380 ft.
NC Well Contractor Certification Number I
15.OUTER CASING for multi-cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER] THICKNESS MATERIAL
Company Name ,t o 0 ft. B5 It' 6.1/4 ;'n sdr21 GALv
prw1202004043 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: G FROM TO DIAMETER' 1 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 Oi Municipal/Public ft. ft. in.I
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.-GROUT' 4
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 rt• bentonite chips pour
Monitoring DRecovery 0 ft. ft cement truck
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck e, rain size,etc.
p ft. 60 ft. soil
4.Date Well(s)Completed:6/8/2021 Well ID# 60 rf 80 ft' soil/sandrock
5a.Well Location: m ft. 425 ft bluegranite
Wade Johnson
Facility/Owner Name Facility ID#(if applicable) ft. fL
Fannie Simmons Rd ft. fL Q
Physical Address,City,and Zip ft. ft.
Surry r21:REMARKS �+
. ,.:., �:,t• CEO.,, r
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.CerTition:
N W . ' ( � • 6/15/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor I 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 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 921 remarks section or on the back of this form. 1
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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (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 a 200'and 2Q1001 construction to the following:
10.Static water level below top of casing: 55 (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 Injection 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
i
13a.Yield(gpm) 35 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: H(h Amount: 16 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 I Revised 2-22-2016