GW1-2021-07630_Well Construction - GW1_20210903

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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 291 ft- 292 fL
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'for.malti-cased wells OR LINER if a "licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESSI MATERIAL
Company Name 0 ft. 72 ft' 6.1/4 1° sdr21 pvc
0607066 16.INNER CASING
TUBING(geothermal dosed-loo
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 []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) h, fL in.
Industrial/Commercial E311esidential Water Supply(shared) 18,:GROUT
h'ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 21 ft. bentonite pour
Monitoring ElRecovery ft. fa
Injection Well:
ft. fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a' livable
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROMI TO DESCRIPTION color,hardness,soilfrock type ia size,etc.
0 ft. 40 fL soil
4.Date Well(s)Completed:2/25/2021 Well ID# 40 ft. 67 fL soil/sandrock
5a.Well Location: 67 ft. 325 ft. blue granite
Speaks ft. fL
Facility/Owner Name Facility ID#(ifapplicable) ft. fL
4789 White Plains Rd ft. rL
Physical Address,City,and Zip ft. ft 61 0�
Wilkes 21.RENLARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
� (2
3�1p Sew,
(if well field,one latllong is sufficient) 22.Cert�ce n: `1
N W " - f,-yV��(/�� \\ , 3/4/2021
6.Is(are)the well(s)C)Permanent or [3Temporary 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: ®Yes or ®No 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 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 ifdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing:43 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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) 7 Method of test: Sight 24c.For Water Supply&Injection 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: 16 completion of well construction to`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