GW1-2022-04636_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown IV 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3308 585
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER`if it licatile
Raymond Brown well Company, Inc FROM TO DIAII�TER THICKNESS MATERIAL
f1. 47 ft 61/4 in• I d2l pvc
Company Name
FRWL2�21�3132 16:INNER CASING OR (geothermal closed-loo ;
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.
-17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public k. ft. int
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) k rt in!
IndustriaUCommercial ((Residential Water Supply(shared) 18.GROUT
. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft. Chips Pour
Monitoring pRecovery ft. ft.
Injection Well:
f4 ft
Aquifer Recharge Groundwater Remediation
'e 19.SAND/GRAVEL PACK'if applicable)
'
Aquifer Storage and Recovery E3Saliniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology EISubsidence Control k. ft.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG ettacb additional sheets if necessary)
Geothermal (Heating/Cooling Return) Mother(explain under#21 Remarks) FROM To DESCRIPTION color,harda soil/rock type,grain size,etc
0 ft. 4 ft. soil
4.Date Well(s)Completed:3/4/22 Well ID# 4 ft. 625 ft* granite /
5a.Well Location: ft. ft.
Adam Lowe ft. ft. ME 12 2022
Facility/Owner Name Facility ID#(if applicable) ft. ft.
irik
145 Poor Valley Trail rywo/115OG
Physical Address,City,and Zip ft. ft.
furry .21.'RENIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N w 3/4/22
6.Is(are)the well(s)(IPermanent or OTemporary Signs remretu of Certified 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: [3Yes or EJNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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#11 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: 625 (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 1Q100') construction to the following:
10.Static water level below top of casing:4 (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 Infection 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) 2 Method of test: Sight 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submitJorie copy of this form within 30 days of
13b.Disinfection type: HTH Amount: z5oz 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 Resources Revised 2-22-2016