GW1-2022-04683_Well Construction - GW1_20220512

P-rint Foram_ �,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 0 ft. 0 ft.
0 ft. 0 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a' IIeable
Raymond Brown well Company, Inc FROM SOS DIAMETER THICKNESS MATERIAL
Company Name
16.INNER CAS G OR TUBING Isothermal closed-loop) pvc
2.Well Construction Permit#:
EHWP2106-020 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in:
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) g• ft
Industrial/Commercial DResidential Water Supply(shared)
1S:GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. '30 fL Chips Pour
Monitoring DRecovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge D Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer 20:DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltmck type,gnin siz etc.
0 ft- 28 ft Soil
4.Date Well(s)Completed: 1/4/22 Well ID# 2e ft. 43 ft Sand Rock
5a.Well Location: +3 ft. 1000 ft. Red Shale
Douglas Burke
Facility/Owner Name Facility ID#(if applicable) ft. ft
292 Gibson Rd rt. ft.
Physical Address,City,and Zip ft. ft MAY 1
Rockingham :21.REMARKS :
kltomation Prot
County Parcel Identification No.(PIN) Ufl�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N W g01.yp1,,J //l 1/4/22
6.Is(are)the well(s)OPermanent or DTemporary Signature d0tertified Well Contractor Date
By signing this form,1 hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes 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#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 I GW-I 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: 1000 (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 2Qa 100� construction to the following:
10.Static water level below top of casing: 0 (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 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) 0 _ Method of test: sight 24c.For Water Supply&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: Amount: 30oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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