GW1-2021-07563_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
200 It- 209 ft.
2312
ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER if a ticable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 48 ft• 6.1/4 in sdr21 pvc
89 4027$6138 116.INNER CASING'OR TUHING(geothermal closed-loopl
2.Well Construction Permit#: C7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC.County,State,Variance,etc.) in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
X Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) ft. tt. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• bentoniie pour
Monitoring :Recovery
Injection Well:
Aquifer Recharge DGroundwater Remediation
,,19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) E3 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,etc.
0 ft. 18 ft. soil
4.Date Well(s)Completed:01/04/2021 Well ID# 18 rt. 40 ft. soil/sandrock
5a.Well Location: 4e % 225 ft- bluegranite
Lawson
Facility/Owner Name Facility ID#(if applicable)
586 Brooks Rd. Reidsville
Physical Address,City,and Zip ft. ft. g+C19
Rockingham 21.REMARKS
County Parcel Identification No.(PIN) 1 \n O OW
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N 0- �1 01/18/2021
6.Is(are)the well(s)OPermanent 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: [3Yes or E]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 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 ifdifferent(example-3@200'and 1@1 construction to the following:
10.Static water level below top of casing: 52 (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 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) 15 Method of test: Sight 24c.For Water Supply&Iniec1tion 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 to the county health department of the county
where constructed.
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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