GW1-2021-06403_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
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2312 ' I
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 6cabl
Raymond Brown well Company, Inc FROM TO e
DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 88 ft 6.1/4I '" sdr21 pvc
ehwp2106-003 16.INNER CASING OR TUBING .eothermalclosed-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.
17.SCREEN:
Water Supply Well:
FROM TO DIAMETERI SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft ft in.'
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft ft in
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft bentoniteichips pour
Monitoring pRecovery 0 ft. ft* cement truck
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test J3Stormwater Drainage ft. ft
Experimental Technology [Subsidence Control ft. ft.
i
Geothermal(Closed Loop) (Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiurock type,grain size,etc.
0 ft. 33 ft soil
4.Date Well(s)Completed: 6/8/2021 Well ID# 33 ft. 52 ft. soil/sandrock
5a.Well Location: sz ft 325 % blue ranite
Christine Butchta ft. ft l '
Facility/Owner Name Facility ID#(if applicable)
ft. ft
110 Davis Rd, ft. ft
Physical Address,City,and Zip
Rockingham 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22T
tion:
N w C � � 1 - 6/11/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature 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• ©Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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',4o 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: 325 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: 35 (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 Injection 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) 75 Method of test: Sight 24c.For Water Supply&Iniecti In 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.
Form GW-l. North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016