GW1-2022-04646_Well Construction - GW1_20220512

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: k
Raymond Brown IV 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3308 300 ft- 302 ft.
450 ft. 452 ft.
NC Well Contractor Certification Number 15 OUTER CASING'(for multitasediwells OR LINER ifs Hcat le
Raymond Brown well Company, Inc FROM TO DIAMETER I THICKNESS MATERIAL
0 ft• 116 ft 61/4 1in sd21 pvc
Company Name
PRWL202101938 16.INNER GASINGOR'TUBING eothermalclosed-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. I°•
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 fL fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft.
Industrial/Commercial 1®IResidential Water Supply(shared) 18:GROUT
I hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft' chips Pour
Monitoring DRecovery
Injection Well:
ft. fL
Aquifer Recharge DGroundwater Remediation 19:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test CIStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, in size etc.
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks)
0 ft. 78 ft. Soil
4.Date Well(s)Completed: 12/10/21 Well ID# 78 ft, 110 ft.
Sand Rock
5a.Well Location: 110 ft. 525 ft.
Granite
Bryant Brantley
Facility/Owner Name Facility ID#(if applicable) ft. fL
446 Gilley Rd
Physical Address,City,and Zip ft. ft
SUIT)/ 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
N W U 12/10/21
6.Is(are)the well(s)13Permanent or 13Temporary Signature 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 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 ofthis form.
23.Site diagram or additional wellidetails:
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: 525 (ft•) 24a. For All Wells: Submit this form within 30 days of compaction 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:80 (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) 5 Method of test: sight 24c.For Water Supply&Injection 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: 1.5ib 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
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