GW1-2021-07080_Well Construction - GW1_20210915

1 'PfInt Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
Raymond Brown i4.WATERZONES
FROM TO DESCRrPTION
Well Contractor Name
189 rt• 191 ft.
2313
ft. ft.
NC Well Contractor Certification Number 35:OUTER CASING for muhi-cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER' THICKNESS MATERIAL
0 ft. 53 it. 6.1/4 in. sdr21 pvc
Company Name
wsmf-011760-2021 FROM
INNER CASING OR Tus AM eothermalcl THICKNESS
2.Well Construction Permit#: FROM To DIAMETER THICIaJEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. tt. in.
3.Well Use(check well use): ft. it. in•
17 SCREEN
Water Supply Well:
pP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL fL in.
i lndustrial/Commercial [IResidential Water Supply(shared) 18.GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 23 it- bentonite pour
:)Monitoring pRecovery 0 ft. ft* cement pour
Injection Well:
Aquifer Recharge (Groundwater Remediation '
'19;SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EIStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ff. ft.
Geothermal(Closed loop) Tracer 20DRILLING LOG attach additional sheets if necessary)
FROM To DESCRIPTION color,hardness,Geothermal(Heating/CoolingReturn) Other(explain under 421 Remarks) soiVrock a rain size etc.)
0 ft. it. soil
4.Date Well(s)Completed:8/2/21 Well ID# 0 ft' 45 ft. soil/sandrock
5a.Well Location: 45 ft. 245 ft• blue ranite
Marcy Mays ft. ft. w—dnic
ft. fL stl a•.,,.,
Facility/Owner Name Facility ID#(if applicable) B+k
5118 Friendship Circle ft. ft
Physical Address,City,and Zip ft
Yadkin ;21.REMARKS r,;.*_ty Cnr 51re i i
DVV R SQ,';ClOII
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.Certification:
N W C �ltc�� `. 8/11/21
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well t7ontractor 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: 13Yes or ONo with ISA 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: 245 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
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.) k
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 Method of test: Sight 24c.For Water SuoDiv&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: 8 completion of well construction to the county health department of the county
where constructed. h
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016