GW1-2022-04718_Well Construction - GW1_20220511

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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 N/A ft. N/A ft.
0 ft. 0 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weus)OR`LMR ifs" 6cable
Raymond Brown well Company, Inc FROM TO DIAMETER THICtQVESS MATERIAL
0 fi• N/A ft.
61/4 i° sd21 pvc
Company Name 16.MNER CASING OR TUBING eothermal'drised-loo
2.Well Construction Permit#: 1966 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. I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OMunicipal/Pub►ic ft. ft. in.'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. N/A ft Hole Plug Pour
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.'SANDlGRAVEL'EACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. fL
Experimental Technology E3Subsidence Control
Geothermal(Closed hoop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin C oligg Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc
ft. fL Red Clay
4.Date Well(s)Completed:2/21/22 Well ID# ft. ft. Sand Rock
5a.Well Location: 170 ft. 525 ft Blue Granite
Deborah Paylor ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
61 Germantown Rd ft. ft.
Physical Address,City,and Zip ft. ft
MAY I
Caswell 21.'REAIARKS
County Parcel Identification No.(PIN) Pr Unk
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWQMW
(ifwell field,one lat/long is sufficient) 22.Certification:
N W /J/2/21/22
6.Is(are)the well(s)oPermanent or Temporary Signature o ertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Elves or []No 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 I 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: 525 (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 1@100) construction to the following:
10.Static water level below top of casing: 63 (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 addi i tion 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.)
i
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: T H Amount: 16oz 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