GW1-2021-07081_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information: I
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Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 403 ft• 405 it
2313 ft. fL
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NC Well Contractor Certification Number ;15.OUTER CASING for in cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 ft. 1 6.1/4 ,' In sdr21 pvc
Company Name
o$ww-O 1 OZO5-2OZO `"16.INNER CASINGOR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I 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
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) All.GROUT
_111nigation FROM I TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 24 fL bentonite pour
Monitoring .Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVELPACK(if applicable)
.
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal eatin CooliII Return) Other(explain under#21 Remarks) FROM T DESCRIPTION color hardn soiUmck e, rain 5' etc
O k. 50 ft. SOLI
4.Date Well(s)Completed:01/27/2021 Well ID# 50 ft. 65 ft. soil/sandrock
5a.Well Location: 85 ft. 425 ft- blue ranitefL
Heather Collins-Roberts ft' " 't t'I V
Facility/Owner Name Facility ID#(if applicable) ft. fL
Swan Creek Bypass ft. ft
Physical Address,City,and Zip ft. ft rral3 �,I i E'^•CP;?SIik�7 u1Z
Yadkin 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.Certification:
N W 4" - \.t� l ', 4/22/2021
6.Is(are)the well(s)13Permanent or Temporary 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: ®Yes or ONo with 1 SA 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 I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
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 ifdifferent(example-3 200'and 2@1001 construction to the following:
10.Static water level below top of casing:65 (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: 1 (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) 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: Hth Amount: 17 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