GW1-2021-00613_Well Construction - GW1_20211222

Pr.;int Form .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
200 ft• 225 tt.
2313
ft i
. ft
NC Well Contractor Certification Number 15.OUTER CASING formuhitased wells OR LINER if a Iicable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 72 fi- 61/4 in' sdr2l pvc
Company Name
3543 16:INNER CA$ING OR TUBING: eothermatdosed-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.
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in
:-)Industrial/Commercial DResidential Water Supply(shared) 48.GROUT .
hrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Hole Plug Pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
p� 19.SAND/GRAVEL PACK.if a livable `
Aquifer Storage and Recovery Lam'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3 Stormwater Drainage ft. ft.
Experimental Technology ®I Subsidence Control ft. ft.
Geothermal((Heating/CoolingReturn) Other(explain under#21 Remarks 0 GM ft. T� ft DESCRIPTION
CRIPaI sheets if,hardness,
( ) Clay
(color,hardness,soil/rock e,grain size,etc.
Geothermal Closed Loop) Tracer 20 DRILLING LOG attach addition
4.Date Well(s)Completed: 10/26/21 Well EN 20 ft' 67 ft. sandrock
Sa.Well Location: 87 ft. 245 ft. Blue Granite
Kevin Vaughn ft. ft F
Facility/Owner Name Facility ID#(if applicable) ft. ft ' s
1192 Dillard Walnut Cove ft. rc
Physical Address,City,and Zip fr. ft.
Stokes 21.REMARKS
Wz! C,clxtf V,
County Parcel Identification No.(PIN)
16 t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W � f � J ( 10/26/21
6.Is(are)the well(s)CIPermanent or [ITemporary Signature&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: ElYes or JqNo 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: 245 (ft) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Injection 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) 50 Method of test: sight 24c.For Water Supply&Iniectii n 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: 6°Z completion of well construction toi the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016
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