GW1-2021-06415_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: e
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
230 ft, 233 IL �
2312
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for moltitased wells OR:LINER if a 6cable-
Raymond Brown well Company, Inc FROM TO DIAMETER, THICKNESS MATERIAL
Company Name 0 ft. 80 ft 6.1/4 f rn' I sdr21 pvc
A6 INNER CASING ORTUBING(geothermal duse d-loo
ehWp2104-013
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): ft. ft. in.
17.
Water Supply Well: FROM SCREEN,TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public fL ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft.
Industrial/Commercial [3Residential Water Supply(shared) 18.'GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite chips pour
Monitoring DRecovety 0 ft. ft cement truck
Injection Well: ft, ft
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if.a licable
ju
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(mlor,hardness,soil/rack type,gmin size,etc.)
0 k• 35 ft soil
4.Date Well(s)Completed:6/7/2021 Well ID# 35 ft. 53 ft soil/sandrock
5a.Well Location: 53 ft 505 ft blue ianite
Andrew Mitchell
Facility/Owner Name Facility ID#(if applicable) ft. ft
8580 Friendship Church Rd. ft. rt 5
Physical Address,City,and Zip f`' f` �S
Rockingham .21.REMARtts rn w J
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:
N W - (�. � 1 6/8/21
6.Is are the wells Permanent or Temporary Signature ofCertised 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: [3Yes 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-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: 505 (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@100) construction to the following:
10.Static water level below top of casing: 10 (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 Iniection Wells: In addition to sending the form to the address in 24a
Air Rotary 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.)
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) 5 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: 22Oz 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 ResourcesE Revised 2-22-2016