GW1-2021-07575_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
290 ft* 297 ft.
2312
ft. ft. i
NC Well Contractor Certification Number
15"OUTER CASING formniti-casedwens OR LINER if a Ilcable
Raymond Brown well Company, Inc FROM To DIAMETER THICKNESS MATERIAL
0 ft 92 ft. 6.1/4 , in sdr21 pvc
Company Name
Ib.INNER CASING OR TUBING- eSthermal closed-loo
2.Well Construction Permit#: NA FROM L TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. I ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) f8:GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft* bentonite pour
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK(if,applicable)
pn
Aquifer Storage and Recovery C3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. it.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG:attach additional abeets if necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiVrock typeI gmin size,etc.
0 tt. 9 it. soil
4.Date Well(s)Completed: 1/26/2021 Well ID# a ft. 85 ft. soil/sandrock
5a.Well Location: as ft. 305 ft. blue granite
Jo';4,Johnson ft. It.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1281 Goin Rd. ft. It.
Physical Address,City,and Zip ft. ft P
Stokes 21-REMARKS ,. n
County Parcel Identification No.(PIN)
1,3t10r d'%011
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Certification:
N W `� . 0. ` - 03/11/2021
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: ( 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 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: 305 (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 2@100) construction to the following:
10.Static water level below top of casing:40 00 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 (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) 100 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. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016