GW1-2022-04685_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond BroWnl ll 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTTON
2313 280 ft• 282 ft
390 ft' 393 ft.
NC Well Contractor Certification Number J5.'OUTER CASING for multitase&wens'OR LINER•if a''Gea61e
Raymond Brown well Company, Inc FROM TO DIAMETER TLLLCKNESS MATERIAL
0 ft- 103 ft- 61/4 in• sd21 pvc
Company Name �tt� '
E I I V V P2006-0 1 6 -16.INNER CASING (geothermal closed-loop)
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2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:,SCREEN
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
Industrial/Commercial ®IResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. @0 ft. chips Pour
Monitoring E3Recovery ft. to
Injection Well: @ ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL-PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
c Geothermal eating/Coohn Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wil/rock type,grain size,etc.
0 ft. 53 ft. Soil
4.Date Well(s)Completed:6/3/21 Well ID# 53 ft. 95 ft. Sand Rock
5a.Well Location: 95 ft• 425 It- Granite
Mack Brame fc. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
297 Brady Club Rd ft. ft.
Physical Address,City,and Zip ft. ft.
Rockingham
21.REMARKS froww4aw Pr4(�
County Parcel Identification No.(PIN) r liner DWQ40G
,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 6/3/21
6.Is(are)the well(s)f3Permanent or ®ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes 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 ofthe copy ofthis 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 ifdi,(ferent(example-3 t@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,
Ifwater 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&Iniection Wells: In addition to sending the form to
the address(es) above, also Submit I one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1$Oz completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources E Revised 2-22-2016