GW1-2021-07091_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
FROM TO I DESCRIPTION
Well Contractor Name
2312 zso ft- zss ft.
ft. it.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased;wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fL 1 1a2 ft. 6.1/4 In. sdr21 pvc
Company Name
GA
PRWL202021rJ9 %i6:lNNERCASINRTUBING eotbetruslclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG 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 �Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) g. fL in_
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
.Geothermal
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 5 rt. bentonite pour
Monitoring Recovery 6 ft- 20 ft cement truck
Injection Well:
ft. ft.
Aquifer Recharge 13 Groundwater Remediation
19.SAND/GRAVEL PACK it applicable)
Aquifer Storage and Recovery 3 Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. fL
Experimental Technology DSubsidencc Control ft. ft
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solUrocktype, in s' etc.
0 rt• 88 it. SOLI
4.Date Well(s)Completed:2/24/2021 Well ID# ss ft. 175 ft. soil/sandrock
5a.Well Location: 775 ft. 520 fL blue granite
Seal ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
151 Fleetwood LN ft. ft.
Physical Address,City,and Zip ft. ft.
Surry 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certifieatio
N W � - - 4/29/2021
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: E3Yes or ONo 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: 520 (it-) 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@100D construction to the following:
10.Static water level below top of casing:90 (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) 200 Method of test: Sight 24c.For Water Supply&Mimi on 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: 24 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016