GW1-2021-06406_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
s
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 172 ft- 173 it
2313 '
298 ft* 294 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER d applicable)
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. too it. 6.1/4 i° sdr21 pvc
Company Name
ehwp2l O2-O 17 '16:INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER TRICKINESS 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 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 IL bentonite pour
Monitoring E3Recovery ft. ft.
Injection Well: ft. IL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK it applicable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness solllrock a rain size,etc.
0 ft. 80 ft. S011
4.Date Well(s)Completed:3/30/2021 Well ID# ft. ft. soil/sans rock
5a.Well Location: 80 ft. 325 It. blue granite
Harry Lee Harrelson ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
181 Reid Lake Rd tt. rL u 5� Oft
Physical Address,City,and Zip ft. ft.
Rockingham 21.REMARKSr
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
N W
_ 4/22/2021
6.Is(are)the well(s)(3Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or ONo with I5A NCAC 02C.0100 or 15A NCAC 62C.0100 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 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 if different(example-3@200'and 2@I00) 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: (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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 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: 17 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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