GW1-2021-00611_Well Construction - GW1_20211222

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond C Brown III 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
125 B• 126 it.
2313
sat R• saz ft.
NC Well Contractor Certification Number
15.OUTER CASING for OR LIIYER if a" licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESSI MATERIAL
0 ft. ft. 6.1/4 ! `ia 1 sdr21 pvc
Company Name
's16:INNER CASING OR TUBING eothermafclosed-loo
3515
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Pubbc ft. ft. in'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
Industtial/Commercial Residential Water Supply(shared) 18.GROUT _
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 tt chips pour
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a "licable -
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stonnwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary);
Geothermal eatin Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc
0 ft. 13 ft. soil
4.Date Well(s)Completed: 7/13/21 Well ID# ft. ft' sandrock
Sa.Well Location: 13 ft. 465 ft- granite _
Mike Rothstein ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. O E C 1
3212 Shepperd Mill Rd Sandy Ridge, NC 27046 rt. %
Physical Address,City,and Zip ft. ft.
Stokes 2L 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 � �o C a`.v Vi c�tii Gi I� _ 7i'4 :/i,I.j 1 S/2
6.Is(are)the well(s)oPermanent or Temporary Signature of Ce ified Well Contractor ate
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: E3Yes or EJNo with ISA NCAC 02C.0100 or ISA 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: 365 (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:60' (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) 10 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: 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 Revised 2-22-2016