GW1-2021-00612_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
Well Contractor Name FROM TO DESCRIPTION
2313 380 ft- 382 ft• i
ft. ft.
NC Well Contractor Certification Number °:15 OUTER CASING formaiti cased'Wells OR LINER ifs livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 IL43 ft- 61/4 1 in- I d2i pvc
Company Name
.16 INNER CASINGOR TUBING eothermal dosed-loo
2.Well Construction Permit#• 3571 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1n.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: FROMSCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) -ft. ft. ;n•I
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• chips pour
s Monitoring E3Recovery ft. ft.
Injection Well:
ft. it.
Aquifer Recharge Groundwater Remediation
19:`SAND/GRAyEL PAC I{ if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer '20.DRILLINGISOG attach.additiomi►_sheetsif necessary)'
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock a rain size,etc.)
0 ft. 22 ft. soil
4.Date Well(s)Completed:9/13/21 Well 1D# 22 ft. 35 ft. soil/sndrock
5a.Well Location: f. 425 ft- granite
Richie Fahnestock et. it
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3364 Flat Shoals Germanton ft. rt.
Physical Address,City,and Zip ft. ft. ON
Stokes 21.REMARKS v�T
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 JP��,'41M. A G 9/13/21
6.Is(are)the well(s)JIPermanent or E3Temporary SignaturVof Certified 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: ®Yes or MNo 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: 425 (ft-) 24a. For All Wells: Submit this:,form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (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
(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) 30 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: 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
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