GW1-2021-06394_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
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Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 345 h• 345 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESs MATERIAL
Company Name 0 ft. ft. 6.1/4 in sdr21 pvc
3519 16.INNER CASING OR TIIBING(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.
.17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipaVPublic ft. fit. in.;
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. ft. bentonite chips pour
Monitoring 1311ecovery 0 ft. ft. cement truck
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EIStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control fit. it
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardn soil/rocka rain s' etc.
p tt. fit. soil
4.Date Well(s)Completed: 5/24/2021 Well ID# R. ft. soil/sandrock
5a.Well Location: 290 ft. 405 ft- blue r'anite
Horrace&Vickie Flippin ft. ft. *P'
Facility/Owner Name Facility ID#(if applicable) fit. ft. �'Z� L
1055 Flippin Rd fr. ft.
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Physical Address,City,and Zip ft. ft.
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Stokes 21.,RENIARKS r re i US it
ir: ,rl;;�ar���,� 4;
County Parcel Identification No.(PIN) Qciion
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W `V__ C. 6/8/21
6.Is(are)the well(s)OPermanent or OTemporary 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: QYes or EJNo 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 ofthe copy ofthis 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: 405 (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 2@100) construction to the following:
10.Static water level below top of casing:65 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this Ifonn 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) 5 Method of test: Sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 1$Oz 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 Resource f Revised 2-22-2016