GW1-2022-04656_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
2313 240 ft• 286 fL
p ft. p ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LUVER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER' THICKNESS MATERIAL
Company Name p ft. 102 % 61/4 1° sd21 Pvc
PRW L2O22O01 HH 16.INNER CASING OR TUBING eotherroall dosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS INIATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. I ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: J7.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural E]MunicipaVPublic ft. ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g, ft.
Industrial/Commercial E3Residential Water Supply(shared)
18 GROUT ,
Irrigation FROM Trt MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. -010 ft. Hole Plug Cement Truck
Monitoring Recovery 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 [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach_additional sheets ifnecessa
77,
Geothermal (Heating/Cooling Return r3 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardoess,soil/mck type,gnin size,etc.
0 ft. 8 ft, Clay
4.Date Well(s)Completed: 1/25/22 Well ID# 8 ft• 90 ft. Sand Rock
5a.Well Location: so ft. 305 ft. Granite
Tammy Inman f` ft. a
Facility/Owner Name Facility ID#(if applicable) ft. ft
MAY
130 Apostle Lane ft. ft.
Physical Address,City,and Zip ft. ft. 1fftfplt"otl f roce"111t®
Stokes 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 ///1/25/22
6.Is(are)the well(s)13Permanent or Temporary Signature of 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 EJNo with 15A NCAC 01C.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#11 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: 305 (ft-) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@I00D 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 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: 4!
(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) 25 Method of test: sight 24c.For Water Supply&Iniecti In 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: Chlorine Amount: 16oz 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 j Revised 2-22-2016
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