GW1-2022-04728_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
240 2313 ft- 260 ft
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased'weUS OR LINER ifa lica6le
Raymond Brown well Company, Inc FROM TO DIAM 1 F THICKNESS MATERIAL
0 ft. 58 ft 1 61/4 1 IIn' I dr2l pvc
Company Name
2021000065 16.INNER CASING OR TUBING eothermal closed-loo
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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
:))Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
i Industrial/Commercial E3Residential Water Supply(shared) 7178.GROUT
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• hole plug Pour
Monitoring D Recovery ft. ft.
Injection Well: ft. ft.
:)Aquifer Recharge E3Groundwater Remediation
19:SAND/GRAVEL`PACK if applies.ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) I3Tracer 20.DRILLING LOG'attach additional sheets if necessary)r
Geothermal(HcatinglCooliqg Return) r3Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiltrock type,grain siz etc.
0 ft. 20 fL Red Clay�
4.Date Well(s)Completed: 12/20/21 Well ID# 20 ft. 53 ft. Sand Rock
5a.Well Location: sa ft. 300 ft- glue Granite
Kaitlyn Moore ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. fL
393 Tyler Creek Drive rt. IL
Physical Address,City,and Zip ft. fL
Davidson 21.REl14ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W gow / 12/20/2021
6.Is(are)the well(s)OPermanent or OTemporary Signature VZertified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or EJNo 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/his 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: 300 (ft.) 24a. For All Wells: Submit this',form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:32 (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
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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`one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 16oz completion of well construction to Ithe 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 Revised 2-22-2016
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