GW1-2021-00644_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
200 k• 225 ft.
2313 k. ft.
NC Well Contractor Certification Number
`15.OUTER CASING for multi-cssed:wells OR:LINER if a 'livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 1 35 ft. 1 61/4 ia. sd21 pvc
Company Name
PRW L202100493 -1�6.oIMNNER CASING ORTu 1G(geothermal closed-loo -
2.Well Construction Permit#: DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) k. ft. In.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FR MCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public fL ft. In,,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared) 19.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. hole plug pour
.Monitoring F3Recovery ft. ft.
Injection Well:
k. ft
Aquifer Recharge EJ Groundwater Remediation
19.SAND/GRAVEL PACK ifs livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®I Stormwater Drainage ft. ft
Experimental Technology Subsidence Control k. ft
Geothermal(Closed Loop) Tracer 20.DRILLING.LOG.attach additional sheets ifnecessa
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc
0 k• 10 ft red day
4.Date Well(s)Completed: 10-21-21 Well ID# 10 ft. 30 ft* sand rock
5a.Well Location: 30 k' 225 ft bluegranite
Joseph Edwards k. ft r v�
Facility/Owner Name Facility ID#(if applicable)
k. ft. ..
236 Cedar Lake Dr Mt Airy ft. ft DE
Physical Address,City,and Zip ft. ft
furry 21.REMARKS
County Parcel Identification No.(PIN) fir'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
N `fgaazn�� G 1110/21/21
6.Is(are)the weil(s)13Permanent or E3Temporary Signature 1A 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: [)Yes or NNo 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: 225 00 24s. 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@1001 construction to the following:
10.Static water level below top of casing:65 00 Division of Water Resotrces,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:
(Le.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) 8 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: 8oz completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resourccsl Revised 2-22-2016
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