GW1-2022-04645_Well Construction - GW1_20220512

Pint Form: ��
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 240 ft. 242 ft. `
300 IL 302 ft.
NC Well Contractor Certification Number 15.OUTER CASING for-TERI cased`€wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 It. 62 ft- 6 1/4 1 'n sdM pvc
Company Name A
PRWL202200003 16.INNER CASINGORTUBING eothermalclowd-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.
Water Supply Well: IZ'SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft ft in.'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri 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/GRAS'EL,PACK'(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. It.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Traccr 20:DRILLING.LOG attach additional'sheets if nemssa
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wiVrock type,grain size,eta
0 ft. 28 ft, Soil
4.Date Well(s)Completed:3/7/22 Well ID# 28 ft. 55 ft Sand Rock
5a.Well Location: se ft. 325 ft. Granite �'
Gary Williams ft. ft.
IR Facility/Owner Name Facility ID#(if applicable) ft. ft.
440 Baldwin Drive ft. ft
Physical Address,City,and Zip ft It. n rc,"" rA
WA0 Cat bdt(�U
$u" 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 G /1/ 3/7/22
6.Is(are)the well(s)oPermanent or Temporary SSiignatur fCertified 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: [)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 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 (it-) 24a. For Ail Wells: Submit this-form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 30 (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) 40 Method of test: sight 24c.For Water Suonly&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: 15oz 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