GW1-2021-07105_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 DESCREMON
2313 192 ft 192 ft-
289 ft 290 fL
NC Well Contractor Certification Number
15.OUTER CASING 06re.T!L1=edweH f`ii s)ORLINER,-(iGcable
Raymond Brown well Company, Inc FROM To 1 TMCKNF'9S MATERIAL
Company Name 0 ft- 72 ft' 6.1/4 in I sdr21 pvc
-16.INNER CASING OK��TUBING(geothermal dosed400p) 1 :
2.Well Construction Permit#: 3265 FROM TO DIAMETEn THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROMTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) -ft. ft.
Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT
METHOD
&AMOUNT
Non-Water Supply Well: 0 ft 30 ft' bentolnite pour
3monitoring E3Recovery ft. &
Injection Well: ft. ft.
3Aquifer Recharge ®Groundwater Remediation
4 9..SAND/GRAVEL PACK(if,app livable
l
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft. i
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets ifneceisary),
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM I To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 50 ft- soil '
4.Date Well(s)Completed: 9/30/2019 Well ID# 50 ft 65 ft- soil/sandrock
5a.Well Location: 65 ft. 325 % bluegranite
Alex Branch ft fL
Facility/Owner Name Facility ID#(if applicable) & ft. te L­
648 Seven Island Rd ft ft.
Physical Address,City,and Zip ft. ft.
Stokes .'21.REMARKS
County Parcel Identification No.(PIN) D%N I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: F_
(ifwell field,one lat/long is sufficient) 22.Certification-
N W 12/04/2019
6.Is(are)the well(s)(3Permanent or [3Temporary 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 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 I 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: 325 (1`10 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftlifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 80 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy ofthis 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) 5 - Method of test. Sight 24c.For Water Supply&Injection 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: Chlorine Amount: 16 oz 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