GW1-2021-00535_Well Construction - GW1_20211222

Prnt�Form�,.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
245 ft- 246 it.
2313
ft. fL
i'
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licabta
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
O ft- 57 ft 6.1/4 ' in sdr21 pc
Company Name G
17'O5-Snhr—O2JOO FROM ER CASING OR TUBING
AM eothermalclICKNoo
2.Well Construction Permit#: FROM To DIAMETER THICKNESS 117ATER[AL
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.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.!
Geothermal(Heating/Cooling Supply) ROResidential Water Supply(single) fL ft.
industrial/commercial DResidential Water Supply(shared) 18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft bentonite chips pour
Monitoring (-.Recovery
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
rilAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [JStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.,DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soiUmck e, rain siz etc.
0 ft. 6 ft. SOII
4.Date Well(s)Completed: 5/19/21 Well ID# 6 ft. 49 ft. soil/sandrock
5a.Well Location: 49 ft 345 ft- blue ranite
Arthur Loggins ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. It
6600 Brookline Dr. ft. ft
Physical Address,City,and Zip ft. IL `
Guilford 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Certification:
N w 6/3/21
-Ar, �YYl��l9 ( . ,.�•-till 1/
6.Is(are)the well(s)oPermanent or OTemporary Signature oo fertified Well Contractor 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: Oyes or E)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: 345 (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@I00� construction to the following:
10.Static water level below top of casing:33 (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 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) 8 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: 16 completion of well construction to the county health department of the county
where constructed. E
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016