_Well Construction - GW1_20230327 (88)

Pont Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Raymond Brown 111 '`14 WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
650 ft, ft.
2313
ft. fit
NC Well Contractor Certification Number 45.OUTER:CASING forTSUI cased wells'OR•LINER'Na licable - .
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 40 fit. 61/4 1°• sd21 Pvc
Company Name
%161 INNER'CASING'ORTUBING' eotliei•malclosed-loo
0486W
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
N.
Water Supply Well: FROM TO
TO DIAMETER SLOT SIZE THICKNESS MATERIAL'
Agricultural OMimicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) M Residential Water Supply(single) ft, ft. in.
Industrial/Cominercial I0Residential Water Supply(shared) 18:-GROVr'
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft* Hale Plug Pour
Monitoring DRecovery ft. ft
Injection Well:
ft. fit.
Aquifer Recharge I�IGroundwater Remediation
49:'SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology I0Subsidence Control ft. ft.
Geothermal(Closed Loop) )Tracer 4',20..DRILLING LOG'attach additional sheets if necessa
FROM TO DESCRIPTION color,hardness,soil/rock e, raw size,etc.)
Geothermal eating/Cooling Return) Other(explain under#21 Remarks)
0 fit• 20 fit Red Clay
4.Date Well(s)Completed:7/20/22 Well ID# 20 ft. 35 ft. Sand Rock
5a.Well Location: as ft. 665 ft Blue Granite
John Griffin/Bobby Wingler ft. ft
Facility/Owner Name Facility ID#(ifapplicable) fit. ft. MAR 2 i ZU43
Rawhide Rd ft. fit _
Physical Address,City,and Zip ft ft +;'°' '':i 4
Wilkes z13REn1ARIcs:;,r: .
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 OQ4�,� s!� // /7/20/22
6.Is(are)the well(s)oPermanent or [ITemporary Signature&Certified 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: FlYes or INo with ISA NCAC 02C.0100 or 15A NCAC 02C.0100 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 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: 665 (fit) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:30 (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 Injection 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) 6 Method of test: sight 24c.For Water Supply&Injection 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