GW1-2021-07097_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
4
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION i
2313 260 ft. 262 ft
ft. ft. i
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 THrcxNEss MATERIAL
0 ft. 100 ft• 6.1/4 1° sdr21 pvc
Company Name
p rw1202101122 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•
IndustriaVCommercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. bentonite pour
Monitoring DRecovery 0 ft. ft. cement pour
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
1 Aquifer Test OStormwater Drainage ft ft
Experimental Technology 0Subsidence Control k. ft
Geothermal(Closed Loop) ]Tracer 20.DRILLING LOG attach additional sheets if necessary)
i Geothermal(Heating/Cooling Return) ' Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soittrock type,grain size,etc.
0 ft. 46 ft. soil
4.Date Well(s)Completed: 7/2/21 Well ED# 46 rt. 93 ft. soil/sandrock
5a.Well Location: m ft. 285 ft bluegranite
Josh Holder rt. rt. ,. �
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Pheasants Trl. rt. ft
Physical Address,City,and Zip ft. ft
Surry 21.REMARKS 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22ZCdft ar* :
N W - lM/��1 7/23/2021
6.Is(are)the well(s)oPermanent 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: [)Yes or F_JNo 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 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: 285 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 50 (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 Infection 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.) 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) 100 Method of test: Sight 24c.For Water Supply&Injection 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: 12 completion of well construction'to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016