GW1-2021-00628_Well Construction - GW1_20211222

Prin Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: k
1.Well Contractor Information:
Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 unknown ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.`OUTER CASING'fog multi cased'wells OR LINER if a licsble
Raymond Brown well Company, Inc FROM To DLIIMETE It, THICKNESS MATERIAL
0 ft- 42 ft.
61/4 1 in• sdr21 pvc
Company Name
'46INNER CASING ORrTUBING 'eotbermallclosed-loo
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.c.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 fL ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
:')Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
Irrt ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- PO ft. bentonite� pour
t Monitoring [-Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
1%SAND/GRAVEL PACK if ti .licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRII,LING.LOG attach additional sheets if.necessa'
FROM TO DESCRIPTION color,hardness,soilfrock type,gmin size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 k. g ft- day
7/27/2021 fc. rt.
4.Date Well(s)Completed: Well ID# a 35 sandrock
Sa.Well Location: 35 ft' ft. granite
Jessica Hood
Facility/Owner Name Facility ID#(if applicable) ft. ft. 2 ,
2021
1035 Sandy Ridge Trail Pinnacle, NC ft. rL
Physical Address,City,and Zip ft. ft
Stokes :21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)OPermanent or [)Temporary Signature of'Certifled 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: nYes or ONo 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 I 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: 705 (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: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: j
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
I'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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: 1 slbs completion of well construction tol the county health department of the county
where constructed. I{M
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016