GW1-2022-04647_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
280 ft. ft.
2313
0 ft. 0 ft I i
NC Well Contractor Certification Number -15.OUTER CASING for multi cased'wells OR LINER if a' lieable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 87 it. 61/4 1 1° sd,21 pvc
Company Name
PRW L2�22��1 rJ4 16.INNER CASING OR TUBING eothermaldosed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well crostmetion 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 ft, ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in.
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
1 Geothermal
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ZO IL Hole Plug Pour
Monitoring E311ecovery ft. fL
Injection Well:
ft. fL
Aquifer Recharge ElGroundwater Remediation
19.SAND/GRAYELPAGK(if applicable)
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. rL
Experimental Technology E3 Subsidence Control ft. fL
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) C30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc
0 ft. 20 ft, Red Clay
4.Date Well(s)Completed:3/28/22 Well ID# 20 ft• 62 ft' Sand Rock
5a.Well Location: 82 ft• 325 ft• Blue Granite
Mills Ridge Properties
Facility/Owner Name Facility ID#(if applicable) ft. fL
505 Pine Ridge Rd ft. fL
Physical Address,City,and Zip ft. fL
Surry 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22..Certification:
N W P,6,A^&4 i'.f/`,0 t/ 1 A/ 3/28/22
6.Is(are)the well(s)(3Permanent or OTemporary Signature ofCertified 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: E3Yes or ONo with ISA 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 welldetails:
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 (fL) 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@100D construction to the following:
10.Static water level below top of casing:60 (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) 8 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: eOz 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