GW1-2021-07546_Well Construction - GW1_20210903

:^1 111'111
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14;WATER`ZONEs .
Well Contractor Name FROM TO DESCREMON
2312 150 fL 155 fL
fL k.
NC Well Contractor Certification Number 15.OUTER CASING for tnuiti cased wells °OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICIINFSS MATERIAL
Company Name 0 It- 66 fL 6.1/4 rn sdr21 pvc
20-04-wnhr-0243$ 16.INNER CASING ORTUBING eothermalclosed-loo"
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft, in.
3.Well Use(check well use): fL k. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural OMimicipaVPublic ft. ft. in,
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. It. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT.
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 k• 20 ft• cement truck pour
f:)Monitoring D Recovery k, ft.
Injection Well: fL k
Aquifer Recharge E)Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control k. ft.
Geothermal(Closed Loop) EITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIMON(color,hardness,so%frock bTe,grain size,etc
0 fL 58 It. soil
4.Date Well(s)Completed: 12/31/2020 Well ID# 5e ft. 7E ft• ! soil/sandrock
5a.Well Location: ,e ft. 405 IL blue granite ANCaM
Nathaniel Solomon
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. , qo
8054 Pdtched Woods Dr fL I k. L Vn1
Physical Address,City,and Zip ft. ft. 31.0% Oh
Guilford 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22. rtification:
N WA�"U&Q - 01/11/2021
6.Is(are)the well(s)OPermanent 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: [3Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that e
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 weL
construction,only i 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: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of wel
For multiple wells list all depths ifdifferent(example-3 a200'and 2@1001 construction to the following:
10.Static water level below top of casing:25 (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: (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
13s.Yield(gpm) 2 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: Hth Amount: 18 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Wate I Resources Revised 2-22-2016