GW1-2021-07073_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: {e
Raymond Brown yMv 14.WATER ZONES
15
Well ContmctorName OQ FROM TO DESCRIPTION 1
(, 489 ft. 490 ft. f
2313 CEPstn�vti ft. fL
NC Well Contractor Certification Number 7T0„B
O� tpn 15.OUTER CASING.for multi-cased wells OR LINER If a livable
Raymond Brown well Compa T v,'RS."00 FROM TO DIAMETER THICKNESS MATERIAL
ft. 26 ft• 6.1/4 ' in' sdr`21 pvc
Company Name 96.INNER'CASING:ORTUBING eothermalclosed-loo
2.Well Construction Permit#: 0419 FROM TO DIAMETER THICKNESS MATFRIAI.
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.
Water Supply Well: FROME TO DIAMETERi SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft ;n
Industrial/Commercial Residential Water Supply(shared) ;qg.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well; 0 ft- 24 fL bentoriite pour
Monitoring ,Recovery 0 ft. ft' cement pour
Injection Well: ff. ft.
Aquifer Recharge OGroundwater Remediation
'79.SAND/GRAVEL PACK(if a"livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) [3Traeer 20.DRILLING LOG attach addifloiial sheets if necessary)
NGeothcrmal
(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO .DESCRIPTION color,hardness,soil/rock e, rain siz etc.
0 ft. ft- Soil
4.Date Well(s)Completed: 7/13/21 Well ID# 0 ft. 10 ft. soil/sandrock
5a.Well Location: ,o ft. 105 fL blueg ranite
Roger Osbourne ft'
Facility/Owner Name Facility 1D#(if applicable) ft
Mitchell Mill Rd ft. %
Physical Address,City,and Zip ft
Wilkes 21.REMARKS-
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.Ce 'reation: '
N WC 7/23/2021
6.Is(are)the well(s)OPermanent or ®ITemporary Signature of Certified Well 03diritctor ! 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: E)Yes or ONo with 1 SA 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-I 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: 525 (fL) 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@I00D construction to the following:
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
i .
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,l Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I �
13a.Yield(gpm) 75 Method of test: Sight 24c.For Water SuuDly&Iniection 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: 4 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