GW1-2021-07613_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown '14.WATERZONEs
FROM TO DESCRIPTION
Well Contractor Name
244 ft• 243 ft.
2312
rL ft.
NC Well Contractor Certification Number 15.OUTER CASING'for mu ltitased-wells'OR'LiNER? f a 'Iicable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. too ft' 6.1/4 1". sdr21 pvc
Company Name
prW1202002525 `16.IIv1yER CASING ORTUBING eothermal?c7os''e`d-loo'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1F7ROMCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13MunicipaUPublic ft. ft. in•
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single)
industrial/commercial DResidential Water Supply(shared) -18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT/
Non-Water Supply Well: 0 ft. 27 ft- bentonite pour
:]Monitoring Recovery
Injection Well:
ft. ft.
C Aquifer Recharge Groundwater Remediation
.19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage
Experimental Technology EISubsidence Control
Geothermal(Closed Loop) ©(Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
0 ft. 50 11. soil
4.Date Well(s)Completed: 10/20/2020 Well ID# 50 ft. 80 ff. soil/sandrock
5a.Well Location: so ft. 325 ft- bluegranite
Jeanette Fredricks ft. ft.
Facifity/Owner Name Facility ID#(if applicable) ft. ft.
537 Bray Ford Rd. e. it. Q ` �d
s '
Physical Address,City,and Zip ft. ft. p1O�
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 12/29/2020
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: OYes or E)No 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: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100D construction 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"Center,Raleigh,NC 27699-1617
11.Borehole diameter: (►n•) 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) 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: 17 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
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