GW1-2022-04634_Well Construction - GW1_20220512

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft- 525 ft.
a3fa ft. f,
NC Well Contractor Certification Number
'15.OUTER CASING(for -cased,*ellii)Tulti 0 LINER if a0011c T_R__
Raymond Brown well Company, Inc FROM TO DIAMETER I I MATERIAL
Company Name 0 ft- NIA 61/4 1 "" I dr2l pvc
,16.INNER CASING OR-TUBING(itetithernial closed-loop)
2.Well Construction Permit#: CV2021 03225 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:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]'Agricultural []Municipal/Public fL ft. in.
:]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) —fL ft. in.
Industrial/Commercial E)Residential Water Supply(shared)
4&:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. ft.
3monitoring 13Recovery ft. ft.
Injection Well: ft. ft.
rl Aquifer Recharge []Groundwater Remediation 149.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) E)Tracer 20.DRILLING.LOG(a c additional sheets if neces"ry)
FROM TO DESCRIPTION(color,hardiuss,soil/mck type, rain sizl�etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:3/22/22 Well I1D# ft. ft.
5a.Well Location: 265 ft. 625 ft- Blue Granite
Bill Norman Construction ft. ft. a—
Facility/Owner Name Facility ID#(if applicable) ft. ft. Ktutiv
129 Cash Valley Trail ft. ft
Physical Address,City,and Zip ft. IL IvIlAY 12 20
t21.7tE?AARKS.
—on,Pfee-sem
County le- Parcel Identification No.(PIN) DWQMOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 3/22/22
6.Is(are)the well(s)(3permanent or [3Temporary 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 welt: ®Yes or [3No with 15A NCAC 02C.0100 or 15A 1VCAC 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-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: 625 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths irdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing:40 M) 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) 5 Method of test: sight 24c.For Water Supply&Iniectiiin Wells: In addition to sending the form to
the address(es) above, also submitt one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 16oz completion of well construction to tithe county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016