GW1-2021-07077_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,w� �
Raymond Brown �?�" 14.WATER ZONES
Well Contractor Name \ ;1170
OM r171
DESCRIPTION
2313 � 15101L ft. ft
ft. ft.
NC Well Contractor Certification Number r$ 15.°35� �
Raymond Brown well Company,,��G:��` cjQv�`'Or FROM OUTER CASING
it'm DIItiAMETER rnsed s OTHICKNESS R if a hMA1TERlAL
'` s 0 42 6.1/4 sdr21 pvc
Company Name e
O4O8W >16.INNER CASING OR TUBING eodtermal 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. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaVPublic ft. ft in:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•
l lndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft, bentonite pour
: Monitoring pRecovery ft. ft* cement truck
Injection Well:
ft. ft
Aquifer Recharge [Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
rl Aquifer Storage and Recovery EI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [)Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal (Heating/Cooling Return) !Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type min size,etc.)
0 ft. B ft. soil
4.Date Well(s)Completed:4/15//21 Weil ID# S ft. 38 ft. soil/sandrock
5a.Well Location: 38 ft. 225 ft blue granite
Curtis Carey ft. ft-
Facility/Owner Name Facility ID#(if applicable) ft. ft
Molly Ln. ft. ft
Physical Address,City,and Zip ft. ft.
Wilkes 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/long is sufficient) 22.Certification:
N W ` - - lip 5/24/2021
6.Is(are)the well(s)oPermanent or ®)Temporary Signature o 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: nVes or E)No with 15A NCAC 02C.0100 or 15A NC 1C 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. I
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 I 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: 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: 10 (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.)
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Division of Water Resources,1 Underground Injection Control.Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service tenter,Raleigh,NC 27699-1636
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13a.Yield(gpm) 5 Method of test: Sight 24c.For Water Supply&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: isoz completion of well construction t1o'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
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