GW1-2021-00607_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
280 ft• 283 ft.
2313
350 ft* 352 ft.
NC Well Contractor Certification Number ,45::0UTER CASING for multi-L d>wells OR LINER if a Iicable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fa 101 ft. 6.1/4 i" sdr21 pvc
Company Name
l6 INNER CASING ORTUBING eothermafclosed-loo
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. tt. i"•
17.SCREEN,
Water Supply Well: FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. i"•
Geothermal(Heating/Cooling Supply) l hResidential Water Supply(single) ft. fc i"•
Industriallcommercial LjResidential Water Supply(shared) 18.GROUT
lt'ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- hr n�j pour
Monitoring .Recovery 0 ft. ft. p'
Injection Well:
ft. ft. ,
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL T EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. tt.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer X DRILLING LOG'attach additional sheets it necessary),
Geothermal(Heatin Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soiUmck a rain size etc.)
0 ft. 25 ft. SOII
4.Date Well(s)Completed: 7/7/21 Well ID# 25 ft' 94 ft. soil/sandrock
5a.Well Location: 94 ft' /�aS�ft. blue ranite
Wendy Mason ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Frye Rd f�'� ft. ft �
Physical Address,City,and Zip ft. ft -.
Stokes 21.REMARKS
County Parcel Identification No.(PIN) 8 r
DWI
KA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: VFDROTM
UMSWi
(if well field,one lat/long is sufficient) 22.C (cation LNrT
r,
N W �9 7/23/2021
6.Is(are)the well(s)JIPermanent or Temporary Signature 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 Yes or rA
No 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: tJ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ll (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@100D construction to the following:
10.Static water level below top of casing:66 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 addi i tion 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 pushy etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) al,9 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: 20 completion of well construction to the county health department of the county
where constructed. f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources l Revised 2-22-2016