GW1-2021-06382_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
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Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312
390 ft. 391 ft.
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NC Well Contractor Certification Number x15.OUTER CASING for multi-"sed:we US)OR LINER if a ficable
Raymond Brown well Company, Inc FROM TO DIAMETER i THICKNESS MATERIAL
Company Name o(] 0 ft. 140 ft' 6.1/4 f in sdr21 pvc
rw1202003942 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: p FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft• ft. iin.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaUPublic M ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared) 18."GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. fi• bentonite pour
Monitoring pRecovery et. 20 ft. cement truck
Injection Well:
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology E3Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) EllOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,gmin size,etc.
0 ft 38 ft- soil
4.Date Well(s)Completed:4/27/2021 Well ID# 38 ff' 113 ft* soil/sandrock r.
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Sa.Well Location: 113 ft. 425 ft blue ranite
Chris Newsom
Facility/Owner Name Facility ID#(if applicable) rt. fL v t
Toms Creek Ch Rd. It. ft
Physical Address,City,and Zip ft. ft r; M^,f`
Surry 21.REMARKS l
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22.C '►ratio
N w - �- 5/24/2021
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: OYes or ONo with 15A NCAC 01C.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 ofthis 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: 425 00 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: 100 (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: 1 (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
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13a.Yield(gpm) 50 Method of test: Sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 12oz 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