GW1-2021-00639_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
FROM TO DESCRIPTION
Well Contractor Name
250 tt• 252 ft.
3308
fr. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 76 it- 61/4 In' sd21 pvc
Company Name
3473 r: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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OMunicipal/Public ft. ft. in.'
Geothermal(Heatingicooling Supply) OResidential Water Supply(single) ft. ft. io
:)Industrial/Commercial Residential Water Supply(shared) 18:GROUT
hri atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt. kips pour
Monitoring (—'Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. fL
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soit/mck type,grain size,etc.
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks)
0 tt• 52 ft, soil
4.Date Well(s)Completed: 7/9/2021 Well ID# 52 ft. 70 IL r
sandrock
5a.Well Location: m ft 265 ft. granite
Tilley ft. tt. C 2 2 7021
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Flinty Knoll Pinnacle, NC 27043
Physical Address,City,and Zip ft. tt.
Stokes _21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N w 7/92021
,. . . �.,,�1 &2d L .J.-�
6.Is(are)the well(s)OPermanent or Temporary Signature of Ce ifie 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: ®Yes or ONo with 15A NCAC 01C.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 retard 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: 265 (ft-) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 Method of test: sight 24c.For Water Suably&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: 12oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-2016
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