GW1-2021-06396_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 167 ft• 168 rt.
ft. ft.
NC Well Contractor Certification Number i
IS.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. 112 11- 6.1/4 in sdr21 I pvc
3484 16.INNER CASING OR TUBING eothetmal 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. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ROResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
.hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 24 ft bentoniie chips pour
Monitoring DRecovery 0 ft. ft cement truck
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
LJ
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardn soil/mck type,grain size,etc.
0 ft. 100 ft. soil
4.Date Wells Completed: 5/26/2021 Well ID# 100 ft. 107 ft.
p soil/sandrock
5a.Well Location: 107 ft. 225 IL bluegranite a '
David Rizor ft. ft
7a�
Facility/Owner Name Facility ID#(if applicable) ft. ft
20
2635 Asbury Rd.
Physical Address,City,and Zip
Stokes 21.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 _P1- C- l • 6/3/2021
6.Is(are)the well(s)oPermanent or ©ITemporary Signature of Certified Well Contra or 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: Oyes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiijerent(example-3@200'and 1@I00� construction to the following:
10.Static water level below top of casing:40 (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: 6 (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) 15 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: t4 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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