GW1-2021-06317_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
WeIlContractorName `
2313 245 ff• 246 ft• C
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR_LINER if a licable
Raymond Brown well Company, Inc F'RUM TO DIAMETER THICKNESS MATERIAL
0 ft' 57 ft' 6.1/4 ! in sdr21 pvc
Company Name c
17-�5—Snl4 Ir��2J�� 16.3NNER CASING OR TUBING, eothermal dosed-loo
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
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) f0Residential Water Supply(single) fL ft. in.
_.Industrial/Commercial lDResidential Water Supply(shared) 18.GROUT
17r1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• bentonite chips pour
Monitoring p Recovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM To I MATERIAL T EMPLACEMENT METHOD
Aquifer Test EIStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. fL
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) E30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hsrdnes soivrock type,grain size,etc.
0 ft. 8 ft. soil
4.Date Well(s)Completed: 5/19/21 Well ID# 8 ft. 49 ft. soil/sandrock
5a.Well Location: 49 ft. 345 ft- bluegranite 'y
Arthur Loggins fr. f`- „•%
Facility/Owner Name Facility ID#(if applicable) ft. fL
6600 Brookline Dr. ft. fL ato', ,off
Physical Address,City,and Zip ft. ft.
Guilford 21.REMARKS 11-
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. 'Scab
N w _ _ 6/3/21
6.Is(are)the well(s)oPermanent or OTemporary Signature of 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 wet]: OYes or ONo 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 921 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: 345 (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 ct 100� construction to the following:
10.Static water level below top of casing: 33 (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 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.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: Sight 24c.For Water Supply&Infection'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: to completion of well construction to the county health department of the county
where constructed. S
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resourcesf Revised 2-22-2016