GW1-2021-07579_Well Construction - GW1_20210903

Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2312 370 ft- 371 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticsble
Raymond Brown well Company, Inc FROM TO DIAMETER THICKINESS MA F11—
0 f< 5a ft. 6.1/4 i° sdr21 pvc
Company Name
3470 16.INNER CASING OR TUBING(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• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IBResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL bentoriite pour
Monitoring pRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL:PACK:dapplicable)
Aquifer Storage and Recovery I[3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soil/rock type in size etc.
0 ft• 15 ft. soil
4.Date Well(s)Completed:3/17/21 Well ID# 15 ft. 48 ft. soil/sandrock
5a.Well Location: .e ft. 425 ft. blue granite
ID
Steve Brennis f ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1243 Brown Mtn Ch Rd e.
Physical Address,City,and Zip ft. ft. ASS\11(3
Stokes 21.REMARKS` 3 •to
D
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N `l C, 3/30/21
6.Is(are)the wel(s)[3Permanent or Temporary Signature ofCertified Well Contractor T� 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 EJNo with 15A NCAC 01C.0100 or 15A NCAC 01C.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: 425 (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 (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 (in.) 24b.For Infection 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) 5 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: 2z oz completion of well construction ti 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