GW1-2021-06409_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2313 265 rt• 266 ft.
333 ft. 1 334 ft. f
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL.
Company Name 0 1L 50 tL 6.1/4 1° sdr21 pvc
eh$p21 O2-OO2 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public M ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in
Industrial/Commercial Q)Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 ft- bentoni,te pour
Monitoring C—Recovery ft. IL cement truck
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVELPACK(if applicable)
Aquifer Storage and Recovery ®)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG:attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) :Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.)
0 ft. ft. soil
4.Date Well(s)Completed:3/30/21 Well ID# 0 ft. 40 ft. soil/sandrock
5a.Well Location: 40 ft. 335 ft• blue ranite
Bob Willis ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1043 Brooks Rd. ft. ft. 2W
Physical Address,City,and Zip ft. ft.
21.REMARKS K? YO'�L
Rockingham S��i,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W `�'0, 1 I • 5/26/2021
6.Is(are)the well(s)13Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes 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#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: 335 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferent(example-3(200'and 2Q100') 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: 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
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 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: t9oz 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
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