GW1-2021-00609_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
tQat. 'a ft I
2313 vv
ft. rL
NC Well Contractor Certification Number 15.OUTER.CASING for multi-cased wells OR LINER ifa !!cable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 38 ft. 61/4 ' in• I d2i pvc
Company Name
3503 16.INNER'CASING OR TI1131NG' 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. ft. in.
SCREEN
Water Supply Well: FROM TO DIAMETER SLOT StZE THICKNESS MATERIAL
Agricultural [3MunicipaUPublic fL tt in.
:)Geothermal(Heating/Cooling Supply) J§Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) i8:GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt bentonite pour
Monitoring Recovery ft. fL
Injection Well:
ft. ft
Aquifer Recharge E3Groundwater Remediation
19:'SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ®ITracer 20 DRILLING.LOG attach additional sheets if hecetsa
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soilhock a rain size etc
0 ft. 12 ft• day
4.Date Well(s)Completed: 10/18/21 Well ID# 12 ft. 30 IL sandmck'
5a.Well Location: so ft. 525 ft. granite '. ae
Robert Splawn ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. fL DEC 2
1679 McDaniel Rd Pilot Mtn ft. ft
Physical Address,City,and Zip ft. It.
Stokes 21.REMARKS
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 94 6.� 1110/18/21
6.Is(are)the weil(S)oPermanent or Temporary Signature GVCertified 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 MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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: 525 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: 100 (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) 80 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: Chlorine Amount: 1.51b 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