GW1-2022-04687_Well Construction - GW1_20220512

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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
2313 150 rt• 155 ft.
aoo ft' 402 ft i
NC Well Contractor Certification Number 15.OUTER CASING for ma"Jiged wells OR LINER ifs "ticable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 116 ft- 6 114 I j i°• sd2i pvc
E H S F 19�2-�20 16.INNER CASING OR TusING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TffiCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL.
Agricultural []Municipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) fL ft. in,
I Industrial/Commercial I3Residential Water Supply(shared) 1S:GROUT
i 1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We11: 0 ft. 20 ft. Cement Pour
Monitoring E3Recovery ft. ft.
Injection Well:
ft. fL
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVELTACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
0 ft. 30 fL Soil
4.Date Well(s)Completed: 12/16/21 Well ID# 30 tt• 110 it' Sand Rock
5a.Well Location: 110 ft. 500 ft- Granite
Michael Kilgariff
Facility/Owner Name Facility lD#(if applicable) ft. ft.
301 Cross Key Rd Reidsville rt. fL
Physical Address,City,and Zip h• ft. MAY 12 2022
Rockingham 21.REMARKS
County Parcel Identification No.(PIN) k1lofolabon PrOct unA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification•
N W / 12/16/21
6.Is(are)the well(s)oPermanent or ®ITemporary Signature VfCertified 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: DYes or EJNo with 15A NCAC 02C.0100 or 1 SA 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: 500 (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 2@100)
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 (in.) 24b.For Infection 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) 6 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: HTH Amount: 1.51b 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