GW1-2021-07611_Well Construction - GW1_20210903

Pri t Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312 380 ft• 382 ft f
ft. ft.
NC Well Contractor Certification Number
c15.OUTER CASING for multi-cased wells OR LINER if a' Ilcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft• tzs ft 6.1/41 1° Sdr21 pc
prw1202004493 16.INNER CASING OR TUBING(geothermal dosedaoo
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 E3Municipal/Pubfic ft. ft. In:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, It.
lndustrial/Commercial [3Residential Water Supply(shared)
18.GROUT
.1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft, bentonite pour
Monitoring E3Recovery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK'if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. fL
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LUG attach additional sheets if necess
Geothermal(Heating/Cooling Return) ElOthcr(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,solDrock type,grain size,etc.
0 ft. 83 ft. soil
4.Date Well(s)Completed:2/16/2021 Well ID# 63 ft. 120 ft. soil/sandrock
5a.Well Location: 120 ft. 425 fL blue granite
Angel McCloud ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft
3133 Wards Gap Rd. ft. ft. s�r9
Physical Address,City,and Zip ft. fL
Surry 21.REMARKS '
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 W --E - C 3/01/2021
6.Is(are)the well(s)OPermanent or Temporary SignaTure of Certified Well CoVVn``t actor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or EJNo 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 I 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 if different(example-3Q200'and 2Q100D 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: (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) 30 Method of test: Sight 24c.For Water SuDDiv&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: 18 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016