GW1-2022-04676_Well Construction - GW1_20220512

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W ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 7VV E
it. rt. I ;
NC Well Contractor Certification Number 15c OUTER CASING for multitasI d wells OR LINER if a licatile
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. 1 82 ft 6.1/41 1 in sdr21 pvc
352 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. ft. in.
3.Well Use(check well use): ft. tt. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)MunicipaUPublic ft. ft. in.
Geothermal(IIeating/Cooling Supply) R Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT
Irri at1On FROM TO Me wRtAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 fL H lu !, Pour
Monitoring DRecovery ft. ft. pour
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 J3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) (3Traeer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness soil/mck e, rain size,etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks)
•� 0 ft. 25 ft. SOII
4.Date Well(s)Completed: �1J�IaI Well ID# zs ft. 75 ft. soil/sandrock
5a.Well Location: 75 ft. 425 ft. blueg ranite
Michael Perrell ff. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
9908 Baux Mountain Rd. rt. ft.
Physical Address,City,and Zip R' ft.
Stokes .21.REMARKS LIM
County Parcel Identification No.(PIN) DwQfBOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: �7 �
N W Rag/, I.CJ"'I�(1 /W •+ 1 //..2J�✓%
6.Is(are)the well(s)OPermanent or 1ITemporary S ignaturlfaf 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 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 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 (It-) 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:30 (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
rn.
( ) 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: h
(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) 2 Method of test Sight 24c.For Water Suppiv&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: 20®Z 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