GW1-2021-00606_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown j i M WATER ZONES
FROM TO D CRIPTION
Well Contractor Name ES
150 ft- 152 ft.
a- 3 300 ft. 302 ft
NC Well Contractor Certification Number 15 OUTER CASING(for-mn'I ed wells OR LINER if Qcable
Raymond Brown well Company, Inc FROM TO DIAMETER TffiCKNESS MATERIAL.
0 ft 113 ft 61/4 in, sd2l pvc
Company Name
3527 16.INNER CASING OR TUBING(geothermal 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. ft. in.
3.Well Use(check well use): ft. ft. in.
37.SCREEN
Water Supply Well:
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL.
Agricultural E]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
Industrial/Commemial Residential Water Supply(shared) 18.'GROUT
73 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft chips pour
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
I9 SAND/GRAVEL PACK;01'applickble
11 Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach`additional'sheets,if:necessa
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock a rain size,etc.)
0 ft• 78 fL soil
4.Date Well(s)Completed: 10/14/21 Well ED# 78 ft 106 ft sand rock
5a.Well Location: 106 ft. 325 ft- Granite
Katherine Perrell ft
Facility/Owner Name Facility ID#(if applicable) ft, ft. DE
3356Brown Mountain Rd Piolt Mtn ft.�:±fLt
Physical Address,City,and Zip ft. t rmw
Stokes 21'REMARI{s , i. h'l:
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
N W R"lwi C �� /l t 10/14/21
6.Is(are)the weti(s)J3Permanent or Temporary SignaturRof 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: n Ves 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 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: 325 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (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
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13a.Yield(gpm) 40 Method of test: sight 24c.For Water Supply&Infection: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: 18Oz 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