GW1-2022-04741_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Raymond Brown iii 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 660 ft. 660 ft
0 ft. 0 ft L.
NC Well Contractor Certification Number 15.OUTER CASING for u �ased'-wells OR'LWER if a `licable.
Raymond Brown well Company, Inc FROM TO mltiDIAMETER' THICKNESS MATERIAL
0 I'L 45 ft. 61/4 C Itn• I d,21 pvc
Company Name
2�21 Q���9� 16.INNER CASING OR[TUBING 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: 19.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial IDResidential Water Supply(shared) 18.GROUT
hri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. I a D ft Hole Plug Pour
Monitoring pRecovery ft. ft
Injection Well:
ft
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,soil/rock type,gnin size,etc
0 ft• 10 IL Red Clay
4.Date Well(s)Completed:2/11/22 Well ID# 10 ft. 40 ft sand Rock
Sa.Well Location: 40 ft. 705 ft. Blue Granite
Sean Rooks ft. fL
Facility/Owner Name Facility ID#(if applicable) ft
OPMMIM
1328 Sierra Trace Rd
Physical Address,City,and Zip ft. ft MAY 11 2022
Davidson 21.REMARKS
County Parcel Identification No.(PIN) n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
N W i+ ,,, 2/11/22
6.Is(are)the well(s)OPermanent or Temporary Signanue r�i°Certified 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: [)Yes or MNo 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 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: 705 (It-) 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: 202 (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.)
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) 15 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
typ �, 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection e:_ r( 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