GW1-2021-00580_Well Construction - GW1_20211222

F"int_Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
960 ft- 962 ft.
2313
0 ft. 0 ft.
NC Well Contractor Certification Number
15.OUTER CASING'for multi-cased wells OR LINER ira livable .
Raymond Brown well Company, Inc FROM TO DIAMETER' TLHCL(NESS MATERIAL
Company Name
0 ft- 62 It' 6.1/4 1" Sdr21 pvc
`16.INNER CASING OR TUBING eother al closed-loop)_
2.Well Construction Permit#: EHWP2108-012 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public fL fL in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial []Residential Water Supply(shared) 19.GROUT
1 lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• chips pour
Monitoring pRecovery ft. ft.
Injection Well:
ft. f4
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test R3Stormwater 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,soillreck rain s' etc.)
Q ft. 25 It. soil
4.Date Well(s)Completed:9/2/21 Well ID# 25 rc' 55 it' sandrock
5a.Well Location: 13 ft. 465 ft- granite
Richard Clark ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
250 Bonnie Lou Ln Reidsville, NC 27320 ft. rL
Physical Address,City,and Zip ft. ft. 2 20211
Rockingham 21.REMARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certification:
N W (I"W8/21
6.Is(are)the wells)f3Permanent or 13Temporary Signature ofCerti ed 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 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 I 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: 1,125 ft
P ( 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 65 (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
13a.Yield(gpm) 5 Method of test: Sight 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 40 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
i