GW1-2021-07569_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) I For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
141 it• 142 ft.
2312 815 ft* 816 ft.
NC Well Contractor Certification Number 15:OUTER CASING for multl cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICLavESS MATERIAL
Company Name 0 ft ft 6.1/4 j i°. sdr21 pvc
ehwp2004-002 16.INNER CASING OR TOEING eothermal'closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER'S SLAT SIZE THICKNESS MATERIAL.
Agricultural [3MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 25 ft• bentonite pour.Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVELPAC&if a livable
Aquifer Storage and Recovery E3Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. it.
Experimental Technology Subsidence Control ft. I ft.
Geothermal(Closed hoop) Tracer 20.DRILLING'LOG'attach additional sheets if necessa
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type in size,etc.
0 ft- 60 ft. soil
4.Date Well(s)Completed:3115/21 Well ID# 60 ft. 78 ft.
p soil/sandrock
5a.Well Location: 78 ft. 925 ft- blue granite
Hong Dao ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. it.
208 Sitting Rock Dr. ft. ft. P
Physical Address,City,and Zip ft. ft Nil oGeSs
Rockingham 21.REMARKS rm3 C
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification: t
N W C- 1 - 03/18/2021
6.Is(are)the well(s)j3Permanent or E3Temporary Sign re ofCertified 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: E3Yes or Oi No with 15A NCAC 02C.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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 925 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if difj'erent(example-3 tQr 200'and 1Q100D construction to the following:
10.Static water level below top of casing: 55 (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 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) 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: 31 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
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