_Well Construction - GW1_20230327 (45)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
580 ft. ft
2313
rt. fL
NC Well Contractor Certification Number 15:OUTER CASING for multi cased wells OR LINER if a Gwble)
Raymond Brown well Company, Inc FROM TO DIAILDsTER THICKNESS MATERIAL
0 ft. 664 ft- 61/4 In sdr21 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
JC Agricultural IOMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) ,18.GROUT
1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
Monitoring ORccovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19:SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG,attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 20 it. Red Clay
4.Date Well(s)Completed:5/20/22 Well ID# 20 ft. 49 ft. sand Rock
5a.Well Location: as ft. 605 ft- Blue Granite PT ft.
--
Berkley Hall Company
Facility/Owner Name Facility ID#(if applicable) ft. ft. r 0223
13
Flat Rock Rd ft. fa
Irac:_•; ,: :±..^n '"c• is i.r,:;
Physical Address,City,and Zip ft. ft.
Rockingham 21c REMARKS :;;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
N W // 5/20/22
6.Is(are)the well(s)oPermanent or E3Temporary Signature Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or )No with 15A NCAC 02C.0100 or ISA 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 tivell 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: 605 (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 2@100) construction to the following:
10.Static water level below top of casing: 35 (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:
(Le.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 276994636
13a.Yield(gpm) 50 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: Chlorine Amount: 16oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental.Quality-Division of Water Resources Revised 2-22-2016