GW1-2021-00602_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 111 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
150 ft• 152 fL
2313
380 ft• 383 fL
NC Well Contractor Certification Number I5.OUTER CASING for multi cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THfCKNESS MATERIAL
0 ft. 85 It* 61/4 in' sd,21 pvc
Company Name
3574 16.INNER CASING OR TUBING 'eothermal closed-loop)
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. iL in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft• ft. in.
Geothermal(Heating/Cooling Supply) joResidential Water Supply(single) ft. fL in.
:)Industrial/commercial E3Residential Water Supply(shared) 18.GROUT
I hri anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. chips pour
I Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if a llcable
Aquifer Storage and Recovery ®ISalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed hoop) Tracer 20.DRILLING LOG`attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,etc
0 ft. 60 ft, soil
4.Date Well(s)Completed: 10/11/21 Well ID# 80 ft. 76 ft. sandrock
5a.Well Location: 78 ft. 425 ft red shell
William Hines ft. ft. r
Facility/Owner Name Facility ID#(if applicable) ft. ft. #+F i Y1
1120 Kayla Ridge Rd Walnut Cove, NC 27052 ft. ft.
Physical Address,City,and Zip ft. ft.
Stokes 21.REMARKS
County Parcel Identification No.(PIN) 'i�� r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N ``n C // 1 10/11/2021
6.Is(are)the well(s)OPermanent or 1ITemporary Signatur of 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: E]Yes or NNo 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 alsojattach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi�jerent(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 enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 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: 25oz 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