GW1-2021-06299_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) �, For Internal Use Only:
1.Well Contractor Information: 0
Raymond Brown Otis "44:WATER ZONES
4� -C, FROM TO DESCRIPTION
Well Contractor Name C�p G��ey � k• ft.
2312 l C c�tG it.
NC Well Contractor Certification Number r .^y�` ,� 15.0UTER CASING'for multitased wells OR LINER if a ticable
Raymond Brown well Company;,,Mc O FROM TO DIAMETER TffiCKNESS MATERIAL
0 ft. 180 f" 6.1/4 iO sdr21 pvc
Company Name
2021007 16.INNER CASING OR TUBING' eothermal closed-loo
2.Well Construction Permit#: FROM I 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): k. tt. in.
W 1 Well: 17.SCREEN
ater Supply y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3MunicipaUPublic ft ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 118.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 35 ft. bentonite pour
Monitoring [—Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
LJ
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ii necessa
FROM TO DESCRIPTION color,hardy soil/mck rein s' etc.
Geothermal eatin Coolin Return) Other(explain under#21 Remarks)
0 ft• eo fL soil
4.Date Wetl(s)Completed:04/02/2021 Well ID# 80 rr' 173 ft, soil/sandrock
5a.Well Location: 173 ft. 605 rt• blue granite
Allen Oakley ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL
4320 Grubbs Rd ft. fL
Physical Address,City,and Zip ft. ft.
Forsyth 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
N W _ C_ -" ,__4 ( � 4/22/2021
6.Is(are)the well(s)(3Permanent or E37remporary
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: [3Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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 pageto 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: 600 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:60 (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 Infection 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
13a.Yield(gpm) 2 Method of test: Sight 24c.For Water Supply&Injection 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: 20 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