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HomeMy WebLinkAboutGW1-2023-00001_Well Construction - GW1_20230102 w ®, NORTH CAROLINA ilk WELL CONSTRUCTION RECORD (GW-1 ) EnvfronmertmfQua(Iry Form GW-1 Well Construction Electronic Form North Carolina Department of Environmental Quality Division of Water Resources November1 Submission ID# G W 1-2023-00001 Are you submitting a scanned form?* Yes No CONTACT INFORMATION ....................................................................................................................... Contact Name* Email Address* Raymond Brown Well Company rbrownwellco@gmail.com Is this a revision to the form you have previously submitted?* Yes No WELL CONSTRUCTION INFORMATION ........................................................................................................................................................................................................................................................................................................................................................................................................................................................ 1.Who is installing these wells?* Owner Well Contractor 1.Well Contractor Information: Certiticate# Cert Level First Name Last Name Company Name 2312 A CHRISTOPHER BULLINS RAYMOND BROWN WELL COMPANY 2.Well Construction Permit#: 3727 List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County, etc.) What type of well is this?* Injection Well Non-Water Supply Well Water Supply Well(includes irrigation wells) 3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial Irrigation Municipal/Public/Community Residential Water Supply(single) Residential Water Supply(shared) Wells> 100,000 GPD 4.Date well was completed and ID# Date Well Completed* Well ID# Well Yield 12/21/2022 100 (gallons per minute)" 5.Well Location Facility/Owner Name* Robert Wall Facility ID# (Required) (If applicable) County* Parcel Identification No.(PIN) Stokes Physical Address* Street Address 1060 Jack Joyce Road Address Line 2 City State/Province/Region Pilot Mountain NC Postal/Zip Code Country 27041 US Latitude* 36.4393504000 Longitudek80.4188516000 Decimal degrees Decimal degrees ........ ................ ......... ........................... ........................... ......... ......... ......... ................... 6.Is(are)the well(s):* Permanent Temporary 7.Is this a repair to an existing well:* Yes • No If this is a repair,fill out known well construction information and explain the nature of the repair under#21 remarks section or on the back of this form. For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed. 8a.Indicate TOTAL NUMBER of wells drilled: 9.Total well depth below land surface: (ft.) 405 9a.What is the depth of the casing from ground surface? For multiple wells list all depths if different (example-3@200'and 2@100') in feet 10.Static water level below top of casing: (ft.) 50 11.Borehole diameter: If water level is above casing,use"+" in inches 12.Well construction method: Auger Air Rotary Cable Tool Direct Push Mud Rotary Rotosonic Other 13. FOR WATER SUPPLY WELLS ONLY: 13a.Yield(gpm) 100 13a. Method of test: If applicable 13b. Disinfection type:* 13b.Amount:* HTH 16oz 14.WATER BEARING/FRACTURE ZONES From To Description unknown 385 in feet in feet 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) From To Diameter Thickness Material 0.00 35.00 6.25 sdr21 pvc in feet in feet in inches 17.SCREEN From To Diameter Thickness Material in feet in feet in inches 18.GROUT From To Material Emplacment Method&Amount 0.00 20.00 Hole Plug Pour in feet in feet 19. SAND/GRAVEL PACK(if applicable) From To Material Emplacment Method in feet in feet 20. DRILLING LOG From To Description(color, hardness,soil/rock type,grain size,etc.) 0.00 10.00 Red Clay in feet in feet 10.00 30.00 Sand Rock in feet in feet 30.00 405.00 Blue Granite in feet in feet 21. Remarks 22.Site diagram or additional well details: You may upload additional well construction information here. pdf only CERTIFICATION INFORMATION * By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. 23.Certification Signature of Certified Well Contractor