GW1-2021-06385_Well Construction - GW1_20210915

,�"':Print Forme,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
1s2 ft• 163
2313 is
198 ft. 199 ft.
NC Well Contractor Certification Number 15.OUTER CASING for 7u1111 sed wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER+ THICKINESS MATERIAL
Company Name AO 0 ft. 81 ft. 6.1/4 1 !n' sdr21 pvc
prw12020043�6 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. I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
3 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
IIri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 23 ft. bentonite chips pour
Monitoring D Recovery 0 ft. ft. cement truck
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if aimlicable
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology EISubsidence Control
Geothermal(Closed Loop) [)Tracer 20.DRILLING LOG'attach additional sheets if necessa
Geothermal(Heating/CoolingReturn) (— Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock a rain size,etc.)
0 ft. 60 ft- soil
4.Date Well(s)Completed:6/1/2021 Well ID# 60 r`' 75 r`' soil/sandrock
Sa.Well Location: 75 ft. 225 rL blue ra'nite
Nathan Marshall
Facility/Owner Name Facility ID#(if applicable) ft. ft. t\A,N
243 Pinnacle TO ft. rL - gore``'•,
Physical Address,City,and Zip
Surry 21.REMARKS \l
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. ertificati
N W - 6/7/21
6.Is(are)the well(s)OPermanent or OTemporary Sign tore of Certi ed Well Contractor Date
By signing this form,I hereby certify thatIthe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes 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 constriction 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: 225 (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: 35 (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
Air Rotary 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) 15 Method of test: Sight 24c.For Water Suaaly&Iniectionl 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' 17Oz 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