GW1-2021-00638_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 290 11- 292 ft•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TD DIAMETER THICKNESS MATERIAL
0 ft• 61 ft 61/4 i° sd21 pvc
Company Name
INNER CASING OR TUBING(geothermal dosed-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. ft- in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.!
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ;n
Industrial/Commercial Residential Water Supply(shared)
3S:-GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL chips pour
Monitoring pRecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft. fL
19.SAND/GRAVELPACK if applicable),
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. %
Experimental Technology D Subsidence Control ft. I ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,wiltmek type min size,etc.
0 ft. 36 ft. soil
4.Date Well(s)Completed:9-14-2021 Well ID# 36 ft. 74 ft. sandrocli
5a.Well Location: 7e ft. 305 ft granite
Larry Lawson ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. fL
1280 Otis Stephens Rd Lawsonville, NC 27022 ft. fL
Physical Address,City,and Zip ft. It.
Stokes 21.REMARKS l
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 .� .0 lx�`-1/1 ( 9-14-2021
6.Is(are)the well(s)oPermanent or Temporary 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: E3Yes or EJNo 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-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: 305 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200 and 2@100D construction to the following:
10.Static water level below top of casing:44 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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: 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