GW1-2021-06313_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 482 483 ft.
2313
ft. rL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 155 fL 6.1/4 I" sdr21 pvc
Company Name
21-03-wn h r-01936 16.INNER CASING OR TUBING`(geothermal closed-loop)
2.Well Construction Permit#: FROM To DIAMETER TIDCIQVESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Valiance,etc.) ft fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROME TO DIAMETER i SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public 0 ft- 160 ft. 4 in. cement/sand
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 25 fL bentonite pour
Monitoring Recovery ft. ft.
Injection Well: ft ft
Aquifer Recharge 13Groundwater Remediation
19.SANDlGRAVELtPACK if applicable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©I Stormwater Drainage ft. ft.
Experimental Technology EISubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if,necessa
Geothermal (Heating/Cooling Return Other(explain under 421 Remarks) FROM To DESCRIPTION color,hardy soil/rock rain s' etc.
0 ft• too fL soil
4.Date Well(s)Completed:3/14/9/21 Well ID# too ft. 150 fL soil/sandrock
5a.Well Location: ,60 ft. 600 ft. blue granite
Jordon Rives ft -
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5689 Church St. ft. rL
Physical Address,City,and Zip ft. fL
Guilford 21.REnIaRKs •.'
,oyClat3E, ��`vdd\.
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.CertificaS2on; ' ✓V
N W � ( � 4/16/2021
6.Is(are)the well(s)OPermanent or Temporary Signature or fCertified 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: [3Yes or EINo with 15A NCAC 02C.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 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: 600 (ft-) 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: 56 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 1 (in.) 24b.For Infection 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) 10 Method of test: Sight 24c.For Water Supply&Iniectiol n 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 Resources Revised 2-22-2016