GW1-2021-07566_Well Construction - GW1_20210903

P Ir nt For
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
600 «• 602 ft.
2312
fit. «.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER d a Rcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Q ft- 115 ft' 6.1/4 la 1 sdr21 pvc
Company Name
ehwp2010-002 16.INNER CASING OR TUBING(geothermal closes-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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) «, ft. in.
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fit. bentonite pour
Monitoring . Recovery fit. ft.
Injection Well:
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK.ff a liciible
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control «. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolie Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soft/rockrain size,etc.
Q ft. 53 ft. soil
4.Date Well(s)Completed: 1/11/2021 Well ID# 53 «• 105 ft. soil/seindrock
5a.Well Location: 105 ft. 645 fL blue granite
Craig Williams « ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
120 Penn Rd. « fL 2
Physical Address,City,and Zip fit. % unt
Rockingham 21.REMARIZs 4 n County Parcel Identification No.(PIN) 6N9 e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 1 . 2/22/2021
6.Is(are)the well(s)j3Permanent or ®ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or ONo with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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: 645 (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 to of casing: 35
p g: (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: (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) 40 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: 20 oz 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

Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well#
Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local#
Page 1 of 4 VDH HDIN#
VDH PWSID#
*Indicates required field or section
**Indicates required field or section,if applicable
1.Contact Information*
Contact: Name Address Phone
Owner Britt&Megan Morton 255 Cimarron Ln
Driller Raymond C.Brown, III P.O.Box 337,Danbury,NC 27016 336-593-8239
System Provider
2.Well Location*
Physical Address:255 Cimarron Ln County/City:Grayson
Subdivision Name: Section: Block: Lot:
Tax Ma /GPIN#•
Latitude: N Longitude: W
Datum Source Horizontal: ❑ WGS84 ❑ NAD83 ❑ NAD27
Lat/Long Source(Check One): ❑ Map ❑ GPS ❑ PPDGPS ❑ Survey ❑ Imagery ❑ WAAS
Location Information Collected B
Physical Location Description:flat
3.Facility&Use*
Type of Facility Check One): Type of Use Check All That Apply):
0 Private 0 Drinking/Domestic Use ❑ Agricultural ❑ Food Processing
❑ Waterworks ❑ Manufacturing ❑ Irrigation ❑ Injection
❑ Observation/Monitoring Well ❑ Geothermal(cooling/Heating) ❑ Fire Safety
❑Closed
❑Open:❑Returned to Surface
❑Returned to Aquifer
4. Well Construction*
Well designation,Name or Number:20-138-043
Date Started:02/22/21 1 Date Completed:02/22/21 Type Rig:
Class Well (Check One): ❑ I ❑ HA ❑ IIB ❑ IIIA ❑ IIIB 0 IIIC , ❑ IIID ❑ IIIE ❑ IV
Construction T e Check One): 0 New ❑ Existing-Modified: ❑ well ❑ Pump:Date 0
Well Depth:125 ft. I Total Hole(borehole)Depth: 125 ft. Depth to Bedrock:50 ft.
Hole Size(Include reamed zones): 0 inches from 0 to 125 ft. Inches from to ft.
Height of Casing above Land Surface: 1 ft. inches
Casing Size(LD.)and Materials: (below) Total Depth of Casing: 76 ft.'
0 inches from 0 to 48 ft.❑infiued Material pvc Weight perlft.sdr2 or wall thickness in.
inches from to ft.❑infined Material Weight perft. or wall thickness in.
inches from to ft. ❑infined Material Weight perK or wall thickness in.
Screen Size&Mesh:
inches from to ft. ❑insued Mesh Size Type
inches from to ft. ❑infined Mesh Size Type
inches from to ft. ❑infilled Mesh Size Type
Water Zones: from to ft. from to ft. from to ft.
Gravel Pack:
Size: Type: from to ft. Size: Type: from to ft.
Grout Type: 20 Grouting Method: Type of Seal:
®Bentonite Slurry ❑Neat Cement from t0 ft. 0 Poured from surface ❑pitless adapter
❑Bentonite pellets/chips❑Concrete ❑Poured through tiemmie pipe 10 sanitary seal
❑Neat Cement(6%bentonite) �omt0 ft. ❑Pumped from bottom upward,
Camera Survey: ❑ Yes ❑ No I Date Conducted:
Additional Well Construction Form Information Attached: ❑ Yes ❑ No

Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well#
Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local#
Page 2 of 4 VDH HDIN#
VDH PWSID#
Well designation,Name or Number*:20-138-043
5.Disinfection
Well Disinfected: ❑ Yes la No I Date:
6.Abandonment *When abandoning the well, Sections 1 thru 4 must be completed and/or attach original GW-2
Date Started: I Date Completed:
Static Water Level(unpum ed level measured): ft.
Casing Size(I.D.)and Materials: I Casing Pulled: ❑ Yes ❑ No ❑ Uncased Well
Depth of Fill: —Type and Source of Fill:
Grout: From to Type: From to Type:
Method of permanently marking location:
7.Pump Test**
Static Water Level(unpum ed level measured):96 ft.
Date: 7/12/19 1 Method(Check One): ❑ Water Tape ❑ Airline ❑ Transducer la Other
Stabilized measured pumping water level: ft.
Date: I Method(Check One): ❑ Top of Well ❑ Top of Casing ❑ Surface Level
Test Pump Intake Depth: ft I Stabilized Yield: gpm after hours
Natural Flow: ❑ Yes ❑ No Flow Rate 50 gpm
Estimated Well Yield: gpm
8.Pump Data**
Type: ❑ submersible ❑ Turbine ❑ Shallow Jet ❑ Deep Jet ❑Other: Motor HP:
Production Pump Intake Depth: ft Rated Capacity: gpm at ft TDH
9. Geologic Information
Type Logs: Aquifer Test Performed:
Water Quality Results Attached: Yes No
Comments:
Formation Lithology Province Geologic Map Used
Elevation
For Office Use

Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well#
Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT;: USGS Local#
Page 3 of 4 VDH HDIN#
VDH PWSID#
*Indicates required field or section
**Indicates required field or section,if applicable
10.Driller's Log(Use additional sheets if necessary)*
Well desi anon Name or Number: 170-17-0125
Depth(feet) Type of Rock or Soil Remarks Drilling Diagram of Well Construction(with
Time dimensions)
Min.
From To (Color,material,fossils,hardness,etc.) (Water,caving,
cavities etc.
0 26 Soil
26 50 Soil/Sand Rock
50 125 blue granite
11.Certification
1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted.Based on my inquiry of the person or persons who manage the system or those persons directly responsible for
gathering the information, the information submitted is to the best of my knowledge and belief true, accurate, and
complete.I am aware that there are significant penalties for submitting false information including the possibility offine
and imprisonment for knowing violations.Signature*: I- A l `- Date: 8/8/19
License Number. 2719001181

f
Form GW-2 COMMONWEALTH OF VIRGINIA DEQ Well#
Revised 8/19/2016 UNIFORM WATER WELL COMPLETION REPORT USGS Local#
Page 4 of 4 VDH HDIN#
VDH PWSID#
*Indicates required field or section
**Indicates required field or section,if applicable
Additional Well Construction Data
(Use and submit only if additional space is needed)
12.Additional Well Construction Data
Well designation,Name or Number:20-138-043
Physical Location:255 Cimarron Ln Date Started:2/22/21 Date Completed:2/22/21
Hole Size(Include reamed zones):
inches from to ft. inches from to ft inches from to ft.
inches from to ft. inches from to ft. inches from to ft.
inches from to ft. inches from to ft. inches from to ft.
Casing Size D. and Materials:
inches from 0 to 96 ft. ❑infiued Material sdr.21 pvc Weight per ft. or wall thickness in.
inches from to ft. ❑infilled Material Weight per ft. or wall thickness in.
inches from to ft. ❑infilled Material Weight per ft. or wall thickness in.
inches from to ft. ❑infilled Material Weight per ft. or wall thickness in.
inches from to ft. ❑infilled Material Weight per ft. or wall thickness in.
inches from to ft.❑infilled Material Weight per ft. or wall thickness in.
inches from to ft. ❑infilled Material Weight per ft. or wall thickness in.
inches from to ft. ❑infilled Material Weight per ft. or walk thickness in.
inches from to ft. ❑infilled Material Weight per ft. or wall thickness in.
inches from to ft. ❑infilled Material Weight per ft. or wall thickness in,
inches from to ft. ❑infilled Material Weight per ft. or wall thickness M.
Screen Size&Mesh:
inches from to ft.❑inacd. Mesh Size Type
inches from to ft.❑infiued Mesh Size Type
inches from to ft. ❑mlied Mesh Size Type
inches from to ft.❑infilled Mesh Size Type
inches from to ft. ❑infiued Mesh Size Type
inches from to ft.❑infiued Mesh Size Type
inches from to ft.❑infiued Mesh Size Type
inches from to ft.❑infiued Mesh Size Type
inches from to ft. ❑issued Mesh Size TvDe
inches from to ft. ❑infilled Mesh Size Type
inches from to ft. ❑infiued Mesh Size Type
Water Zones:
From to ft. From to ft. From to ft. From to ft.
From to ft. From to ft. From to ft. From to ft.
From to ft. From to ft. From to ft From to ft.
From to ft. From to ft. From to ft. From to ft.
Gravel Pack:
Size: Type: From to ft. Size: Type: From to ft.
Size Type: From to ft. Size: Type: From to ft.
Size: Type: From to ft. Size: Type: From to ft.
Grout Type: from 0 to 20 ft. Grouting Method:
0 Bentonite Slung ❑Neat Cement from to ft. ❑Poured from surface
❑Bentonite pellets/chips ❑Concrete ❑Poured through tremmie pipe
❑Neat Cement 6%bentonite from to ft. ❑Pumped from bottom upward
s