GW1-2021-00610_Well Construction - GW1_20210205

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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
160 ft- 161 ft.
2312 490 ft 492 ft-
NC Well Contractor Certification Number
15:OUTER'GASING for multi-cased wells`OR LINER f a ticatile
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft- s5 ft 6.1/4; in. sdr21 pvc
Company Name
EHWF2007-012 16.INNER CASING'ORTUBING "eoth& a]`closed4o'o
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): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TMCKNF.SS MATERIAL.
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18:GROUT
l 1rri ation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL bentonite pour
Monitoring ;Recovery ft. ft.
Injection Well:
ft. ft.
I Aquifer Recharge DGroundwater Remediation
19:`SANDIGRAVELPACK if applicable)
'
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.-DRILLING LOG attach addifiooal sleets if necessa
Geothermal(Heating/Cooling Return) E30ther(explain under 921 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
0 ft- 64 ft. soil
4.Date Well(s)Completed: 01/08/2021 Well ID# 64 fL 88 ft. soil/sandrock
5a.Well Location: ss ft. 505 ft- bluegranite
Tim Medley ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3080 Country Ln. ft ft.
Physical Address,City,and Zip ft. ft.
Rockingham 21.REMARKS ,
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 W �� _ ` LAM 01/11/2021
6.Is(are)the well(s)OPermanent or Temporary Si�e of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 01C.0100 or 15A 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 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 h e�� / ay use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL r a �/ ction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 X kftgo b a. 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@100) s on to the following:
35 6,s'' > ;:3�ion Processes
10.Static water level below top of casing: n1nIR S#lon Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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) 20 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: Hth Amount 18 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 Resource's Revised 2-22-2016
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