GW1-2021-06427_Well Construction - GW1_20210915

3 WPr.,ilit�Form Via;,
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
300 ft- 325 ft.
2313 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LUKER if a Qcabie
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft s9 ft• 6.1/4 1O sdr21 pvc
Company Name
3545 16.INNER CASING OR TUBING(geothermal closed-loo
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 :' SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) OResidential 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 Well: 0 ft. 20 ft. bentonife pour
Monitoring l—Recovery 0 ft. ft. cement pour
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
SAND/GRAVELPACK if a'1icable
Aquifer Storage and Recovery iDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sbeets if necessary)
,Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.)
0 ft. 25 ft. soil
4.Date Well(s)Completed:6/22/21 Well ID# 25 ft. 64 tt. soil/sandrock
5a.Well Location: g, ft. 345 ft• blue granite f c
Zane McKinney fr. ft' � `:
Facility/Owner Name Facility ID#(if applicable) ft. ft. 2�
4095 NC 8 HWY S ft. fL Ulli�
Physical Address,City,and Zip ft. ft. _r. .,1a:on IOnrS•On
Stokes 21.REMARKS ;i `•
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 �� ti 7/5/2021
6.Is are the wetl(s)o Permanent or Temporary 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: pYes 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 also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 345 (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:43 (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 CeInter,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: Sight 24c.For Water Supply&Infection'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: a completion of well construction to' the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources? Revised 2-22-2016
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