GW1-2022-04670_Well Construction - GW1_20220512

F�. Print Form �;
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
ft. ZZS ft.
2313
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multiased wells OR LINER if a licatile
Raymond Brown well Company, Inc FROM TO DIAtVlETER' THICKNESS MATERIAL
0 ft. 87 fl- 6114 in. sd21 pvc
Company Name
PRW L202102049 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft. in•'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. m
'Industrial/Commercial E31tesidential Water Supply(shared) .18.GROUT
1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: O ft- 20 fL Hole Plug' Pour
Monitoring pRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
,.79.SAND/GRAVEL-PACK ifa livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets if necessary)
Geothermal eatin C olitig Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wil/rocktype, rain s' etc
0 ft. 20 % Red Clay
4.Date Well(s)Completed:2/1/22 Well ID# 20 ft. 52 fL Sand Rock
5a.Well Location: 52 ft. 265 ft- Blau Granite
Ray Southern ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Gentry Farm Rd ft. rL
Physical Address,City,and Zip ft. fL
P Unit
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: r
N W &,4 ,,,d //1 2/1/22
6.Is(are)the well(s)(IPermanent or 07remporary Sipaturgof 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: E]Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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: 265 (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 2@I00D construction to the following:
10.Static water level below top of casing: 52 (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 Iniectlon 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&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 to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources " Revised 2-22-2016