GW1-2022-04753_Well Construction - GW1_20220511

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Print Forme
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 250 ft. 252 ft 1
750 ft. 751 ft.
� ;
NC Well Contractor Certification Number "15.OUTER CASING for multi-cased wells OR LINER if a icable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 f1. 36 ft- 61/4 1°' sdr2l pvc
Company Name
2021 OJ9 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): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fa in;
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft' 00 ft' Chips Pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge (]Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft. ft.
Experimental Technology [3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock a rain size,etc
p ft. 16 ft* Soil
4.Date Well(s)Completed: 1/19/22 Well ID# 18 ft. 30 ft. Sand Rock
5a.Well Location: 30 ft• soy ft- Granite
Joseph Plitt rt. rt
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
4516 Mountain Springs Rd ft. ft.
Physical Address,City,and Zip ft. ft.
Forsyth 21.REMARKS ProcagWV
DWWOU
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 1/19/22
6.Is(are)the well(s)OPermanent or [ITemporary Signature afCertified 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: E]Yes 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 constniction 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-I 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: 905 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths indifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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) 12 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: N Amount: 25 Dy completion of well construction to the 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 I Revised 2-22-2016