GW1-2022-04638_Well Construction - GW1_20220512

' Rrint Form_
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brownlll 14.WATER ZONES;
Well Contractor Name FROM TO DESCRIPTION
2313
605 ft- 645 ft-
0 k. 0 ft.
NC Well Contractor Certification Number 15.OUTER CASING formuki-cased'welIs OR LINER.if a 'Ucable
Raymond Brown well Company, Inc FROM TO DIAMETER, THICKNESS MATERIAL
0 ft. 96 ft. 61l4 j in. sd21 PVC
Company Name
PRW L202102913 I6.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 OMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) ROResidential Water Supply(single) ft. ft. in.l
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
Irri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welb p k. C ft. Hole Plug' Pour
i Monitoring 13 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E313roundwater Remediation
19:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EI Stormwater Drainage k. ft.
i Experimental Technology Subsidence Control k. fL
l Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 k 25 fL Red Clay
4.Date Well(s)Completed: 12/8/21 Well ID# 25 ft. gt ft. Sand Rock
5a.Well Location: 91 k. 705 ft- Blue Granite
Trevor Johnson ft• ft. w
Facility/Owner Name Facility ID#(if applicable) ft. ft.
751 Hodges Mill Rd ft. fL
Physical Address,City,and Zip ft. ft.
L •rl,I\ '21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Certification:
N W �I 12/8/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature o Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo 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 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: 705 (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: 20 (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) 7 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 16Oz completion of well construction to the county health department of the county
where constructed. C
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016