GW1-2021-07615_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 150 I'L 155 ft.
525 fL 527 ft.
NC Well Contractor Certification Number 15.OUTER CASING foe tnuld sed wells ORI INER if a` licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name ) 0 ft. gg ft. 6.1/4; '" sdr21 pvc
p�I r10rL00405c 16.INNER CASING OR TUBING `eothermal closed-loop)
2.Well Construction Permit#: G V 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): tt. ft. in.
Water Su 1 Well: ..17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public [t. it. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft, in•
Industrial/Commercial DResidential Water Supply(shared) 18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 24 ft* cement truck pour
:)Monitoring DRecovery ft. ft.
Injection Well:
fC ft.
!Aquifer Recharge Groundwater Remediation
t19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinityBarrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology oSubsidenGe Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal g/ g ) (explain
) FROM TO DESCRIPTION color,hardness,soillrock c rain size,etc.)
l (Heating/Cooling Coolin Return : Other under#21 Remarks
0 ft. 58 ft. soil
4.Date Well(s)Completed: 12/31/2020 Well ID# 58 ft. 78 ft.
p soil/sandrock
5a.Well Location: ra ft. 565 ft- bluegranite
Donna Jarrell ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
125 Crabapple Ln ft. it. V71
Physical Address,City,and Zip ft. ft.
Surry 21.REMARKS MIA ptp�=�"A
County Parcel Identification No.(PIN) jG10 R Se
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W _ C 01/13/2021
6.Is(are)the well(s)OPermanent or OTemporary Signatufe 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 E)NO with 15A NCAC 01C.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: 565 (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 1 @I00') construction to the following:
10.Static water level below top of casing:45 A) 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 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) 3.5 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: 20 oz 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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