GW1-2021-07544_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2313
NC Well Contractor Certification Number 15.OUTER CASING for mulnased wells OR LINER if a Iicsble
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 tt• 64 ft- 6.1A in• Sdr21 pvc
Company Name
$32 16:INNER CASING OR TUBING eothermal closetl=too
20-12-Wrhr-0$
2.Well Construction Permit#: 8 FROM TO DIAMETER I THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIG County,State,Variance,etc) ft. Iff:
in.
3.Well Use(check well use): t. in.
Water Supply Well: 17.SCREEN
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) -18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 64 ft. cement truck pour
Monitoring [)Recovery
Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
�19:SAND/GRAVEL;PACK ifapplicable)
VISAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG'attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soiUrock a rain si etc.
)0 ft. ft. 5011
4.Date Well(s)Completed:01/14/2021 Well ID# fL ft. soil/sandrock
5a.Well Location: ft. k. bluegranite WE9V
Roger Rierson ft. ft. QL
Facility/Owner Name Facility ID#(if applicable) ft. ft. UAW
1106 Pinoak Rd tt• tt• atlo1PfO °n
Physical Address,City,and Zip
Guilfoord 21.REMARKS
County Parcel Identification No.(PIN) Install d loner exis�ing well
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification•
N W -V_� �*
- �VsL V. 01/18/2021
6.Is(are)the wells)(-(Permanent or Temporary Sign of Certified Well Contractor' Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or MNo 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 construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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: (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: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: (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) Method of test: Sight 24c.For Water Supply&Infection 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: 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
1.