GW1-2021-06412_Well Construction - GW1_20210915

Print:Forrn
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES"
Well Contractor Name FROM TO DESCRIPTION
2313 578 ft- 579 ft•
ft. ft.
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 I THICKNESS MATERAL
0 ft. 50 ft- 6.1/4 In s&21 pvc
Company Name ,16.INNER CASING OR TUBING+(geothermal closed-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 In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural E3Municipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) [IResidential Water Supply(single) fL ft. in.
Industrial/Commercial E3Residential Water Supply(shared) 19.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 22 fL bentonite pour
Monitoring Recovery
Injection Well:
fL fL
Aquifer Recharge E3 Groundwater Remediation
>I9.SAND/GRAVEL PACK:(ifapplicable
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [ISubsidence Control ft. fL
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additiohal_sheets if necessary)
Geothermal eatin COoliII Return Other lain under#21 Remarks) FROM T DESCRIPTION color,hardy soillrock a lain s' etc.
0 ft. 4 40 fL SOLI
4.Date Well(s)Completed:4/6/2021 Well ID# 40 ft. 45 ft. soil/sandrock
5a.Well Location: 45 ft. 625 ft. blue rarlite -�
Jeremy Westbrook ft. M
Facility/Owner Name Facility lD#(if applicable) ft. fL
Flat Rock Rd ft. rL 5
Physical Address,City,and Zip ft. fL
Rockingham 21.REN ARKS p `_: l t
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.Certification: ` 1
N W `� C- 4/22/2021
6.Is(are)the well(s)OPermanent or E3Temporary Signalure of Certified 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: Oyes or E)No 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 625 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 57 (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: (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) 12 Method of test: Sight 24c.For Water Supply&Injection 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: 21 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 2-22-2016