GW1-2021-07548_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
470 ft• 472 ft.
2312 rt. rt. I
NC Well Contractor Certification Number 15.OUTER CASING(for mvIti ased wells OR LINER if a '7icatile
Raymond Brown well Company, Inc FROM �123
O DIAMETER THICKNESS MATERIAL
0 ft' ft' 1 6.1/4 j "" sdr21 pvc
Company Name 4,
20-09—wn11r-06g94 16.INNER CASING OR TUBING `eothermalclosed-loo
2.Well Construction Permit#: J 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 C]Municipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) ft. ft. in:
Industrial/Commercial Residential Water Supply(shared) 5.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 rt. bentonite pour
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
SAND/GRARELPACK if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage
ft. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soilfrock rain size etc.
ft. 30 ft. soil
4.Date Well(s)Completed: 10/27/2020 Well ID# 30 ft. 92 ft. soil/sandrock
5a.Well Location: 92 JIL 505 ft- bluegranite
Ken Malkovich ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1001 Old Hickory Ct. rt. rr.
Physical Address,City,and Zip ft. ft.
Guilford zl.REMARxs;
County Parcel Identification No.(PIN) ggtn9 I11
Inforru't R section
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
N W 12/29/2020
6.Is(are)the well(s)OPermanent or Temporary Signature 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: DYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 01C.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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100� construction to the following:
10.Static water level below top of casing: 30 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: (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,:Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 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: 18 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016