GW1-2021-06395_Well Construction - GW1_20210915

Rrin Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
258 ft. 259 ft.
2313
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 g5 ft 6.1/4 r" sdr21 pvc
3464 16.INNER CASING OR TUBING(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 SLOTSILE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared) 18-GROOT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, bentonite pour
Monitoring .Recovery ft. ft* cement truck
Injection Well: ft. ft
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK it a livable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL 7 EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage ft. ft
PExperimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if,necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type rein siz(,etc.)
0 ft. 7 ft soil
4.Date Well(s)Completed: 5/18/2021 Well ID# 7 ft. 27 ft. soil/sandrock
5a.Well Location: n ft. 585 ft bluegranite
Kevin Schill ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft s
1092 Edwards Rd ft. ft
Physical Address,City,and Zip ft. ft 21
Stokes 2L REMARKS
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 5/26/2021
6.Is(are)the well(s)OPermanent or ®ITemporary Signature of Certified Well on reactor 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 OC 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 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: 585 (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@100D construction to the following:
10.Static water level below to of casin 35
P g� (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (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 pushy 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) 3 Method of test: Sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit ione copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 3t4 completion of well construction to the county health department of the county
where constructed. j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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