GW1-2021-07568_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 110 ft- 112 ft.
2312 228 ft, 230 ft.
NC Well Contractor Certification Number 15.OITPER CASING for rnulti�ased wells OR LINER if a llcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 61 ft. 6.1/4 1O sdr21 pvc
Company Name
16.INNER CASING OR TUBING eotbermal:closed-loo
2.Well Construction Permit#: NA 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. ft. in.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) -ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUP
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- bentonite pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
,19.SAND/GRAVEL-PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft-
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach'additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain she,etc)
Geothermal(Heating/Cooling Return) r3 Other(explain under#21 Remarks)
p ft. 20 ft. soil
4.Date Well(s)Completed: 3/14/21 Well ID# 20 ft. 54 ft. soil/sandrock
5a.Well Location: se ft. 245 ft- blue granite
Brian Angel ft. I
ft
Facility/Owner Name Facility lD#(if applicable) ft. ft.
2412 Pine Valley Rd. ft ft 2
Physical Address,City,and Zip ft. ft. VI��t
Rockingham '21.REMARKS Awn
r�
County Parcel Identification No.(PIN) 1n DwR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
N `f S,_ C_ `�WV\_A�\ - 03/16/2021
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: E3Yes or ONo with 15A NCAC 01C.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 id,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: 245 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 (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 (iu.) 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) 30 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: 14 oz 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 Water Resources Revised 2-22-2016