GW1-2021-00600_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER.ZONES
FROM TO DESCRIPTION
Well Contractor Name
250 ft- 251 fL
2313
375 ft• 376 ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a lieable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 75 ft. 6.1/4' 1° sdr21 pvc
Company Name
3531 :-16:INNER CASING TUBING(geothermal closed-too
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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL bentoriite pour
Monitoring (-Recovery 0 ft. fL cement pour
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
Aquifer Storage and Recovery Salmi ty Barrier FROM
SAND/GRAVEL PACK If applicable)
—
OM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardo soil/mck type,grain size,etc.
0 ft. 30 ft. soil
4.Date Well(s)Completed: 7/14/2021 Well ID# 30 ft. 68 ft. soil/sandrock
5a.Well Location: ft. 405 ft. blue granite
David Yarbrough fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. It. 2 d 202",
3971 Dodgetown Rd. ft. fL
Physical Address,City,and Zip fL ft. -
Stokes 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification: 1
N W `\ 9/2/2021
6.Is(are)the well(s)OPermanent or ®ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or InNo 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: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 60 (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) 100 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 completion of well construction to the county health department of the county
where constructed.
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016