GW1-2021-00630_Well Construction - GW1_20211222

rnt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
E
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 278 ft• 279 ft.
ft. ft.NC Well Contractor Certification Number 15'OUTER CASING foc multi cased:wells OR LINER if a 'Gcsble
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft- 6.1/4 1" sdr21 pvc
Company Name
011893 -76i INNER>CASING OR TUBING "eo m theral closbdaoo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERLIL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) fL ft. in.
3.Well Use(check well use): ft. ft In•
Water Supply Well: a 17:;SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft ft in•.
Industrial/Commercial Residential Water Supply(shared) :18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It 25 fL bentonite pour
Monitoring Recovery 0 ft. fL cement pour
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage fL ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20 DRILLING LOG fattAtbadditionfil,sheits.if.m6essa "
Geothermal(Heating/Cooling Return) rjOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,grain s' etc.
ft. 40 ft. SOLI
4.Date Well(s)Completed:8/18/2021 Well ID# 40 ft 73 ft. soil/sandrock F
5a.Well Location: 73 ft. 405 ft. blue granite
Vernon Sheets ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
553 Mitchell St
cal Address,City,and Zip ft. fL
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 12, C. Vt�(�I�. 8/16/2021
6.Is(are)the well(s)(3Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes 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 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: 405 (ft) 24a. For All Wells: Submit this i form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
i
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
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.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) 6 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: 20 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