GW1-2022-04657_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: k
1.Well Contractor Information:
Raymond Brownlll 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
400 ft. 425 ft. t
2313
p k. 0 ft.
NC Well Contractor Certification Number 15:OUTER,CASING(foe multi-cased wells OR LINER'if a ticable
Raymond Brown well Company, Inc FROM TO DIAMETER; TIHCKINESS MATFniai.
0 ft 45 ft 61/4 I1° sd21 pvc
Company Name
3CGo 16.INNER CASING OR TUBING(geothermal dosed-loop).
2.Well Construction Permit#: JU FROM TO DIAMETER TRICKINESS 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.
174 SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE TRICKINESS MATERIAL
:]Agricultural E)MunicipaVPublic k. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
IndustriaVCommercial Residential Water Supply(shared)
18:GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Q!0 ft• hole plug Pour
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19 SAND/GRAVEL PACK if.a 'licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets;if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock Vpe,grain size,etc
0 ft. 20 ft. red Gay
4.Date Well(s)Completed: 11/24/21 Well ID# 20 ft. 40 ft. Sand Rock
5a.Well Location: 00 ft. 425 ft- blue granite
Katie Knights ft. rL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
E Old Phillips Rd ft. It.
Physical Address,City,and Zip k. ft.
Stokes 21 REMARKS ro
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 11/24/21
6.Is(are)the well(s)OPermanent or Temporary Signature of ertified 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 2JNo with I5A NCAC 02C.0100 or ISA 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: 425 (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:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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.) i
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&Infection;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: $Oz completion of well construction toy 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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