GW1-2023-02401_Well Construction - GW1_20230404

IF-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
Print Form
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES
Well Contractor Name FROM TO DESCRn'1'ION
2313 P89 ft. ft.
ft. ft.
NC Well Contractor Certification Number I5.OUTER CASING for multi cased'wells OR LINER if a liwble
Raymond Brown well Company, Inc FROM TO DIAMETERI THICKINESS MATERIAL
D ft- 47 ft. 61/4 ' lin• sd21 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
PRWL202200927 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: 17:SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
—`Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
�Ilrrijzation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 0 ft- 20 ft. Hole Plug Pour
Monitoring r 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 Stormwater Drainage ft. ft.
Experimental Technology OSubsidcnce Control ft. ft.
Geothermal(Closed Loop) !OTracer 20.DRILLING LOG attach.additi6nal'sheets if necessary)
Geothermal(Heating/Cooling Return) ! Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type in size,etc.
0 R• 20 ft* Red Clay
4.Date Wells Completed: 6/13/22 Well ID# 20 ft. 42 ft.
()Com p Sand Rock
5a.Well Location: az ft. 306 ft. Blue Granite - - - � ,;�. > ;!5� ;:"'
Kevin Nunn ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. /S 2023
265 Bryan Rd ft. ft.
Physical Address,City,and Zip ft. ft
Surry 21..REMARK.S
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification: n
N W ECU,� /�rur�c✓f'I /// 6/13/22
6.Is(are)the well(s)OPermanent or ®)Temporary lA gnamre oVCertified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )]Yes or XX No with 15A NCAC 02C.0100 or 15.4 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 I 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: 305 (fG) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing:45 (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:
(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) 15 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: aoz 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