GW1-2021-06390_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 392 R• 393 ft-
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfiged wells OR LINER if u licsble
Raymond Brown well Company, Inc FROM TD D,AMETER TffiCKNESS MATERIAL
0 ft es IL 6.1/4 in. sdr21 pvc
Company Name
3427 16.INNER CASING OR TusING(geothermal closed-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): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT `
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weil: 0 ft- 23 it. bentonite pour
Monitoring E3Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(il'applicable
Aquifer Storage and Recovery [3 Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. %
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets if necessary)
Geothermal satin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn wil/rock a rain s' etc.
0 k• 60 ft- soil
4.Date Well(s)Completed:4/27/2021 Well ID# 60 ft. 80 ft. soil/sandrock
5a.Well Location: so ft. 505 fL blue granite
Russ Peterman ft. rr �
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
4006 Gordon Rd ft. rL
Physical Address,City,and Zip ft. IL �.r *{ .,`Gn Processing Unit
Stokes _21.REMARKS , 'e^,i'IOn
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- ���� , 4/29/2021
6.Is(are)the well(s)(3Permanent or E3Temporary Signature of Certified Welt-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: E)Yes or E)No 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 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (t-) 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:45 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
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13a.Yield(gpm) 2 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: 18 completion of well construction t�the county health department of the county
where constructed. l
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016