GW1-2021-00641_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
FROM TO DESCRIPTION
Well Contractor Name
385 rt• 400 ft i
2313
NC Well Contractor Certification Number 15.OUTER CASING for maltizdl:wells OR LINER if a IIcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 50 ft- 61/4 1° sd21 live
Company Name 16.INNER CASING OR TUBING(geothermal othermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) k. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public fL ft. In..
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft
Industrial/Commercial ®I Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• hole plug Pour
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL-PACK(if applicable)
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [I Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) E3Tracer ;20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soittrock type,grain size,etc
0 ft. 20 ft* red day
4.Date Well(s)Completed: 3/11/2021 Well ID# 20 ft. 43 ft' sandrock
Sa.Well Location: 43 ft• 425 ft- bmegranite
Patrick Joyce ft. ft.
Facility/Owner Name Facility ID#(if applicable) R. ft. _
3897 Hwy 268 E Pilot Mtn 27041 rt. ft �Zl
Physical Address,City,and Zip k. ft.
Stokes 21.REMARKS ,
County Parcel Identification No.(PIN) vrol
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N `'it 1!" ;P,�� /// 3/11/2021
6.Is(are)the well(s)OPermanent or Temporary Signatur fCertified 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 INNo with 15A NCAC 02C.0100 or ISA 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: 425 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@100) construction to the following:
10.Static water level below top of casing:45 (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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: sight 24c.For Water Supply&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: eoz 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