GW1-2022-04673_Well Construction - GW1_20220512

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Rrint Form.. :
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown Ill 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2313 aoo ft- 425 ft.
ft. ft.
NC Well Contractor Certification Number 15.`OUTER.CASING foemulti�ased`we0s'OR LINER;rf a `licalile'
Raymond Brown well Company, Inc FROM TO DIAMETER! •rrucla'S MATERIAL
0 ft. 69 ft- 61/4 I°' sd2l pvc
Company Name
3434 ?16.INNER CASING OR TUBING eothermal closed-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. In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.',,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial EIResidential Water Supply(shared) 18 GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft hole plug; Pour
Monitoring DRecovery ft. fa
Injection Well: ft. fr.
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
i Experimental Technology Subsidence Control ft. ft.
!Geothermal(Closed Loop) [ITracer 20.DRILLINGLOG attach additional sheets if-mcessa
FROM TO DESCRIPTION(color,hardness,soiUreck e, rain size,etc.
Geothermal eatin Coolin Return) Other(explain under#21 Remarks)
0 ft• 20 fL Red Clay,
4.Date Well(s)Completed:6(4/21 Well 1D# 20 fr. 64 ft. Sand Rock
5a.Well Location: e4 ft• 525 ff• Granite
Rhonda Craig rt. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
3759 Hwy 89 E ft. fL
Physical Address,City,and Zip ft. ft koww4w PfIJe"Gim unk
Stokes 21.REMARKS s y'
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 6/4/21
6.Is(are)the well(s)(IPermanent or Temporary Signature WCertified Well Contractor Date
By signing this form,1 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
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 ito 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: 525 (ft-) 24a. For All Wells: Submit this jform. within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(Qa 100� construction to the following:
10.Static water level below top of casing:51 (ft.) Division of Water Resoul ces,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&Iniecti L 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; 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 Revised 2-22-2016