GW1-2021-00536_Well Construction - GW1_20211222

Prnt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond C Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2313 190 ft- 192 ft.
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for mutti�aced'.wells OR LINER if applicable
Raymond Brown well Company, Inc FROM TO DIAMETER` THICKNE I MATERIAL
0 IL 61 fl 6 114 ' "' sd21 pvc
Company Name
19-06-WN H R-04813 16:1NNER cnslNG OR TUBING eothermatelagea-l°°
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. It. in.
3.Well Use(check well use): ft. ft. in
47.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.'
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' cement Pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
0-1 19.SAND/GRAVEL PACK'if a licable
Ili Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolie Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rockrajas' etc
0 ft. 30 IL soil
4.Date Well(s)Completed:9/8/2021 Well ID# 30 ft. `153� �ft' sandrock
(
5a.Well Location: 53 f' "1 OJ+ft. biue9ranite
Natanael Saloman f<. ft
Facility/Owner Name Facility lD#(if applicable) ft. tL
4908 Gordon Farm Way Brown Summit, NC 27214 ft. ft.
Physical Address,City,and Zip ft. ft. 2 2021
Guilford 2L REMARKS
UW
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification'
N w 2aa6j4nd C �/IL9/8/2021
6.Is(are)the well(s)OPermanent or Temporary ignature o 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 JMNo 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: 465 00 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@100) construction to the following: i
10.Static water level below top of casing:20 (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) 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°Z 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
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