GW1-2021-06389_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 2,14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 442 k. 443 ft.
2313 i
212 k 213 ft'
NC Well Contractor Certification Number 15.OUTER CASING for inulti cased wells OR LINER if applivable
Raymond Brown well Company, Inc FROM DIAMETER THICKNESS MATERIAL
0 fL 53 s3 ft• 6.1/4 � i°• sdr'21 pvc
Company Name
3448 €l6.'INNER CASING OR TUBnvG(geothermal dosed-loop)
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): k. fL in.
17.i"Irrigation
ater Supply Well: FROM SCREENSCRE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 27 fL bentonite pour
Monitoring (—Recovery ft. ft.
Injection Well: k. ft.
Aquifer Recharge Groundwater Remediation
'19.SAND/GRAVEL.-PACK(III applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stotmwater Drainage ft. ft.
Experimental Technology Subsidence Control k. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin C oling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,wittrack type,grain size,etc.
0 ft. 40 ft. soil
4.Date Well(s)Completed:3/10/2021 Well ID# ft. fL soil/sandrock
5a.Well Location: m ft. 500 ft. blue ranite
Ryan Dunman ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
1174 Sechrist Loop Rd. ft. fa
Physical Address,City,and Zip ft. ft 1
Stokes .21.REMARKS
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County Parcel Identification No.(PIN) Cp$51
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
N W \-k, �-_ �`� , 4/22/2021
6.Is(are)the well(s)(3Permanent or Temporary Signature ofCertified 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: E)Yes or E)No with ISA NCAC 02C.0100 or ISA 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 I 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: 500 (ft-) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing:55 (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) 3 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: 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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