GW1-2021-06422_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
Well Contractor Name FROM TO DESCRIPTION
2313 135 ft• 140 ft•
ft. ft.
NC Well Contractor Certification Number I5.OUTER CASING for multi-cased wells 'OR LINER if apRlicable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS I MATERIAL
ft. 6p ft. 6.1/4 in sdr21 GALV
Company Name
16.INNER CASING OR TUBING eothcrmal closed-loop)
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,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 ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R. 21 ft. bentonite chips pour
Monitoring ElRecovery 0 ft. ft. cement truck
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
lAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTraeer 20.DRILLING LOG attach additional sheets if necessary)
Gcothermal(Heating/Cooling Return) "Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type nin size,etc.
0 ft ft. soil
4.Date Well(s)Completed: 5/4/2021 Well ID# o ft. 50 ft. soil/sandrock
5a.Well Location: so ft 205 ft blue granite -k.
Erin Love ft. rt. .
Facility/Owner Name Facility ID#(if applicable)
ft. ft. "-
Gatewood Rd ft ft. CEP
Physical Address,City,and Zip ft. ft -r+ret:$iil �l�l)
Stokes 21.REMARKS liti:ii,,• " " 1
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 C �l�' 6/30/21
6.Is(are)the well(s)oPermanent or Temporary 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: DYes or R_JNo with 15A NCAC 02C.0100 or 15A NCAC 02C.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 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DP..T 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 I 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: 205 (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 1@100D construction to the following:
10.Static water level below top of casing: 103 (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
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) 50 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: 14 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