GW1-2022-04642_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
150 ft• 151 ft. I
2313 f
NC Well Contractor Certification Number 270 ft. 275 ft.15c OUTER CASING for multi-cased wells OR LINER:ifs licelile
Raymond Brown well Company, Inc FROM TO DIAMETER I MATERIAL
0 f1. 1 54 ft- 6114 1° sd2l pvc
Company Name
PRW L202103349 ;-16'INNER CASING`ORTUBINc(geothermal closed400
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 E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) f• ft. in.
Industrial/Commercial Residential Water Supply(shared)
78.GROUT
IrrI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Chips Pour
Monitoring DRecovery ft. ft.
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
19'SAND/GRAVEL PACK'if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage h• ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20 DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittrock type,grain size,etc
0 ft. 26 ft• Soil
4.Date Well(s)Completed: 12/30/21 Well ID# 26 rt' 46 r`' Sand Rock
5a.Well Location: 4e ft• 325 ft Granite
David Bullin ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
652 Stony Knoll Rd
Physical Address,City,and Zip ft. ft.
Surry 21.REMARKS
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 gam r // 12/30/21
6.Is(are)the well(s)OPermanent or Temporary Signature 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: OYes or []No with I SA 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 welfIletails:
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: 325 (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: 35 Division of Water Resou)ces,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.) p
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 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: 15oz completion of well construction to the county health department of the county
where constructed. P
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources E Revised 2-22-2016
E