GW1-2021-00615_Well Construction - GW1_20211222

k
Print Forrn
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
500 ft- 525 ft.
2313
ft. ft.
NC Well Contractor Certification Number 15:'OUTER CASING for 721ti-c d wells OR LINER if a"]icable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL.
0 ft 45 ft• 61/4 in sd21 Pvc
Company Name
3479 16: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.
Water Supply Well: - 17'SCREEN :. '+
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) fL ft.
Industrial/Commercial Residential Water Supply(shared) a8_GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
9 Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
LJ
Aquifer Recharge Groundwater Remediation
19'SAND/GRAVEL PACK'if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer ;20:DRELLING:Loa attach'additional sheets if necessary)'
Geothermal (Heating/Cooling Return) `Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
0 ft. 10 ft* Red Clay
4.Date Well(s)Completed: 11/4/21 Well ID# 10 ft. 40 ft.
Sand Rock
5a.Well Location: a0 ft. 545 ft- slue Granite
Willie McCombs ft• ft. r "
Facility/Owner Name Facility ID#(if applicable) ft. ft. DE
1384 Spainhour Mill Rd ft ft
Physical Address,City,and Zip ft. ft. ryrfi
Stokes 21 REMARKS Pr/t w
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 /� �1
� � 11/4/21
(
6.Is are)the well(s) Permanent or Temporary Sign ertified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or ONo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 421 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: 545 (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@100� construction to the following:
10.Static water level below top of casing:65 (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 addi i tion 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: ff
(i.e.auger,rotary,cable,direct push,etc.)
k
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f
13a.Yield(gpm) 5 Method of test: sight 24c.For Water Supply&Infection.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 aOZ 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 i Revised 2-22-2016