GW1-2021-00610_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
400 ff• 425 ft.
2313 ft. ft.
NC Well Contractor Certification Number "15.OUTER:CASING for multi-cased`wells OR LINER.if a linable
Raymond Brown well Company, Inc FROM TO DIAMETER TBICKNESS MATERIAL
0 ft. 97 ft. 61/4 In' sd21 live
Company Name
3542 16s INNER CASING OR TUBING eothermal'closed-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. ft. in
REE
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
htdustrial/Commercial E3 Residential Water Supply(shared) 18.GROUT
ITrI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft Hole Plug pour
Monitoring DRecovery ft. ft.
Injection Well:
ft. it.
Aquifer Recharge Groundwater Remediation
19.'SAND/GRAVEL PACK:if applicable)
[Aquifer
uifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Test 13Stormwater Drainage ft. ft.
erimental Technology Subsidence Control ft. ft.
thermal(Closed loop) 1ITracer 20 DR1LLiNG LOG attach additional sbeets'ifnecessa ;
thermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock e, rain size,etc.)
0 fi• 20 fL Red Clay
4.Date Well(s)Completed:9/27/21 Well lD# 20 ft. 92 ft' sand rock
5a.Well Location: 92 f' 425 ft Blue granite
Mariana Mendoza ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4564 NC Hwy 8 Walnut Cove ft. ft.
Physical Address,City,and Zip ft. ft DEC2 2021
Stokes 21 REMARKS
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N `' f�,gu_ rw,►7� G //1 9/27/21
6.Is(are)the well(s)j3Permanent or Temporary Signature 6rCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or ONo 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS I
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 if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing:55 (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 m.
(• ) 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) 40 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: 8oz 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
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