GW1-2021-06425_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: i
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION..
Well Contractor Name
2313 280 ft- 283 ft
350 ft. 352 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
0 ft ft 6.1/4 in sdr21 pvc
Company Name 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. tt. in.
17:SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
`Agricultural [3Municipal/Public FL ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft* bentonite pour
Monitoring C-.Recovery 0 ft. It' cement pour
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
rl%Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0 ft. 25 ft. soil
4.Date Well(s)Completed:7/7/21 Well ID# 25 ft' 94 ft. soil/sandrock
5a.Well Location: 93 ft, 545 ft- blue ranite
Wendy Mason IL fr. .'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Frye Rd ft. ft.
Physical Address,City,and Zip ft. ft. EP
Stokes 21.REMARKS
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County Parcel Identification No.(PIN) Q :O
v.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.C •leation:
N w C _ Uw{ 1 _ 7/23/2021
6.Is(are)the well(s) permanent or Temporary Signature of Certified Well Contractor ! Date
By signing this form,1 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 alsoattach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 545 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3Q200'and 2@100D construction to the following:
10.Static water level below top of casing:66 A) Division of Water Resources,Information Processing Unit,
Ifwater 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 ttiisform within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) E
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Slght 24c.For Water Supply&Iniectiou 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: 20 completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016
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