GW1-2021-07596_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313
285 ft. 286 ft.
NC Well Contractor Certification Number
15.'OUTER CASING formunl-cased wells`OR LINER if a Ilcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 75 rt. 6.1/4 1° sdr21 pvc
3386 16.INNER CASING OR TU13ING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) fL 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) OResidential Water Supply(single) in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT _
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' cement truck pour
Monitoring Recovery
Injection Well:
Aquifer Recharge'Groundwater Remediation
519:SAND/GRAVEL PACK if applicable `
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test O Stonnwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
0 ft. 9 ft. soil
4.Date Well(s)Completed: 10/17/2020 Well ID# 9 ft. 68 ft.
P soil/sandrock
5a.Well Location: 68 ft 485 ft- bluegranite
Michael Hallford ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1151 Oscar Frye Rd
Physical Address,City,and Zip
ft. ft.
Stokes 11.REMARKS S
County Parcel Identification No.(PIN) -3 M Sg o
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification:
N w . C- W U l 12/31/2020
6.Is(are)the well(s)OPermanent or [)Temporary Signa re 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 01C.0100 or 15.4 NCAC 01C.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:
S.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: 485 (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@I00� coristmction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service iCenter,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
i
13a.Yield(gpm) 2'5 Method of test: Sight 24c.For Water Suaaly&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: 1.5 Ibs completion of well construction Ito'the county health department of the county
where constructed. i
Forth GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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