GW1-2021-00524_Well Construction - GW1_20211222

Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brownlll 14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
120 k• 123 ft.
2313
k. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a IIcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fL 1 95 ft. 6114 1in• sdr21 pvc
Company Name L�
I R-�9661 16.INNER CASING OR TUBING eothermal closed-loo
21-11—W N f• '
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): k. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural (3Municipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) k. fL in.
IndustriaVCommercial Residential Water Supply(shared)
11i GROUT
h-ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 25 ft. Cement Truck
i Monitoring Recovery k. ft.
Injection Well:
k. fL
Aquifer Recharge DGroundwater Remediation
19.8AND/GRAVEL PACK if applicable)
`
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additiotial sheets if necessary)
Geothermal eatin Coolin Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mek type,grain size,etc
0 ft. 20 fL Soil
4.Date Well(s)Completed: 12/14/21 Well ID# 20 ft. 80 ft.
Sand
5a.Well Location: w ft. B9 ft. Sand Rock
Jason Smith ss ft 605 ft. Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8301 Wrights Farm Lane
Physical Address,City,and Zip ft. ft. DEC 2
Guilford 21.REMARKS
County Parcel Identification No.(PIN) '
WOU
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: TM e
(if well field,one lat/long is sufficient) 22.Certification:
N W ��/�� �I( 12/14/21
6.Is(are)the well(s)(3Permanent or Temporary Signature WCertified 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 ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Weil Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided tojthe 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: 605 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tQ200'and 2Qa 100D construction to the following:
10.Static water level below top of casing:25 (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: 6 (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
i
13a.Yield(gpm) 2 Method of test: sight 24a For Water Supply&Infection 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: 20Oz 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