GW1-2021-00631_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: G
Raymond Brown 14.WATER ZONES -
WellContractorName FROM ft. TO DESCRRTION
ft.
3308 ft I
. rt.
NC Well Contractor Certification Number 15.'OUTER CASING for multi-cased wells OR LINER if a" licab
ft.
le
OM TO DIAMETER' THICKNESS MATERIAL
Raymond Brown well Company, Inc FR ft 1O sdr21 p
Company Name 0 a2 6.1/41 vc
16:INNER CASING-OR TUBING(geothermal closed-loop) '
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. rt. in.
. 17.SCREEN
Water Supply Well:
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in'
Industrial/Commercial OResidential Water Supply(shared) 8.GROUT,
11.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 R- benton,ite pour
Monitoring Recovery 0 ft. ft. cement ! pour
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) EITraeer 20.DRILLING-LOG'attach additional sheets if necessary)
f FROM TO DESCRIPTION(color,hardness,safl/mck e, rain size,etc.)
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks)
Q ft. 15 ft 5011
1 6/30/21 ft. ft.
A.Date Well(s)Completed: Well ID# 15 75 soil/sandrock
5a.Well Location: 75 ft. 605 ft blue ranite
Nathen Hagedorn ft. ft 1
2Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1639 Brookcove Rd. ft. ft
Physical Address,City,and Zip
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.Ration,
N W C ` 7/23/2021
6.Is(are)the well(s)OPermanent or [3Temporary Signature of Certified 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: ElYes or ©INo with ISA 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: 605 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli Brent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service CI nter,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: 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 Ceenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: Sight 24c.For Water Suaoly&Injection 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: 4 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
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