GW1-2021-00627_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown IV 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
90 ft. 92 ft.
3308
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LUKER if a licabie
Raymond Brown well Company, Inc FROM TO DIAMETER; THICKNESS MATERIAL
0 ft. 82 ft- 61/4 I io' ' sd21 pvc
Company Name
3463 16:INNER CASING OR TUBING: eotherinal 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. tt. in.
y7.SCREEN
Water Supply Well:
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft ft. in.'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
:!)Industrial/Commercial [Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 tt. chips pour
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
r7lAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage
Experimental Technology D Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG-attach additionit tsheetsif necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardy soilt o k type rain sa etc
0 ft. 35 it soil
4.Date Well(s)Completed: 7/29/202 Well ID# 35 ft. 75 ft' sandrock
5a.Well Location: 75 k• 525 ft- granite
Wesley Benton
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4239 NC 268 Hwy Pilot Mtn 27041 ft. iL BEP `
Physical Address,City,and Zip ft. ft. l
Stokes 21.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 - t 1 7/292021
6.Is(are)the well(s)CIPermanent or Temporary Signature ofC ified Well Contractor Date
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: MYes or EJNo with 15A 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 921 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
9.Total well depth below land surface: 525 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ii(different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 (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
(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) 2 Method of test: sight 24c.For Water Supply&Iniecti I on 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: 20oz 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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