GW1-2021-06380_Well Construction - GW1_20210915

l Print Form^
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
i
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312 116 ft• 117
241 ft• 242 fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased.wells OR LINER if a able)
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESs MATERIAL
Company Name 0 ft. 80 ft 6.1/4 In. sdr21 pvc
prw1202101 031 -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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in.'
:)Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1ni ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt 25 ft• bentonite chips pour
Monitoring DRecovery 0 It. IL cement truck
Injection Well:
ft. ft. i
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL-PACK if a '1ic9ble
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage tt. ft.
Experimental Technology Subsidence Control ft. ft.
i Geothermal(Closed Loop) D'Tracer 20.DRILLING LOG attach additiomil sheets if necessary)
Geothermal(Heating/Cooling Return) r3Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain siv,etc.
0 k. 60 fL soil
4.Date Well(s)Completed:6/15/2021 Weil ID# 60 ft• 75 tt soil/sandrock
5a.Well Location: 75 ft. 305 ft blue granite
Hugh Brantley ft. rL
w +
Facility/Owner Name Facility ID#(if applicable) ft. ft.
0
355Mears Rd ft. fL - 2
Physical Address,City,and Zip ft. fL
Surry 21.REMARKS
County Parcel Identification No.(PIN) a S
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W 6/22/2021
6.Is(are)the well(s) 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: Yes or �No 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: 305 (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 1@100D construction to the following:
10.Static water level below top of casing: 65 (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 Injection 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) 35 Method of test Sight 24c.For Water Supply&inieeHon'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: 18oz completion of well construction to the county health department of the county
where constructed. kl
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016
i
r