GW1-2022-04629_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 7
Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 250 ft- 265 ft.
0 ft• c ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft 79 ft.
61/4 in. sd21 pvc
Company Name
0734W 16.INNER CASING OR TUBING eothermal 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 []Municipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in,:
Industrial/Commercial Residential Water Supply(shared) 48.GROUT
1 hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- _O ft. Hole Plug. Pour
Monitoring Recovery ft. ft.
Injection Well:
ft. It
Aquifer Recharge 13Groundwater Remediati0
1%SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer ..20.DRILLING LOG'attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0 fi 20 ft, Red Clay
4.Date Well(s)Completed:2/17/22 Well ID# 20 ft. 74 ft Sand Rock
5a.Well Location: 74 ft. 265 fi- glue Granite
Christian Rutherford ft. I ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
8374 Sparta Rd ft. It.
Physical Address,City,and Zip fL prOCt ►'dk't
Wilkes :21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N w9ftn4_"J 6,1� //f 2/17/22
6.Is(are)the well(s)(IPermanent or E3Temporary Signature dYCertified 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 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 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 I 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 M-) 24a. For All Wells: Submit this,'form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: 55 (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:
(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) 5 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: 14 04 Amount: 16oz 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