GW1-2021-07558_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r.
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312 115 rt. 118 ft j
ft. ft. i
NC Well Contractor Certification Number
15.OUTER CASING fot ruin-cased wells)'OR LINER'if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' gp ft' 6.1/4 in' I sdr21 pvc
31313 16.INNER CASING OR 1 UBING(geothermal closed-loop)
2.Well Construction Permit#: 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. tt. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural (3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. tt. in.
Industrial/Commercial [IResidential Water Supply(shared) 18.GROUT_
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft, bentonite pour
Monitoring DRecovery fL ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
'19.SAND/GRAVEL PACK if appilcable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology D Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILI ING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type,gmin size,etc
O ft. 43 ft. Soil
4.Date Wells Completed:01/12/2021 `,hell ID# 43 ft 73 ft.
P soil/sandrock
5a.Well Location: 73 ft. 225 ft- bluegranite
Josh Smith ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
274 Longleaf Ch Rd
Physical Address,City,and Zip ft. ft.
Moore 21 REMARKS
County Parcel Identification No.(PIN) nform3t'On f 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W 41 0 ���. 01/20/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature ofCcrtW4etrWell CoAKctor 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 NCAC 02C.0200 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-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: 225 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well,'
For multiple wells list all depths tfdii ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 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 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) 8 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: 16 oz completion of well construction Ito the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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