GW1-2022-04691_Well Construction - GW1_20220512

��", Print -orm
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 480 ft- 500 ft-
rc. rL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa 'livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 ft. 61/4 in. sd21 pvc
Company Name
EFi WP211�-��7 '16.INNER CASING OR TusING 'eothermal 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. ft. in.
Water Supply Well: .17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3MunicipaVPublic ft. ft. in:
Geothermal(Heating/cooling Supply) MResidential Water Supply(single) ft. ft. in:
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. aentonite Pour
Monitoring pRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.8AND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_s Aquifer Test E2Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING.LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [3Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,seRfmck type,grain siz etc
0 ft. 10 fL Clay
4.Date Well(s)Completed: 12/21/21 Well ID# 10 ft. 60 ft. Sand Rock
5a.Well Location: e0 ft• 500 It. Granite
Carolina Contracting John Holland ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
140 Mallard Ct Reidsville ft. ft. MAY 1
Physical Address,City,and Zip ft. ft.
Rockingham 221.REMARKS, N40111111MM PlOC661lift Unlit
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 ( �rr>rpv► 12/21/21
6.Is(are)the well(s)OPermanent or Temporary Signature fCertified 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: [3Yes 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 jto 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 (fi) 24a. For All Wells: Submit this iform. within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2 100) construction to the following:
10.Static water level below top of casing:45 (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) Method of test: sight 24c.For Water Supply&Injection 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 Ithe 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
I