GW1-2021-07573_Well Construction - GW1_20210903

;Prirlt Form �`'
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
725 ft- 726 fL
2313
ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING'foemulti cased wells OR LINER if a licsble
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL.
Company Name 0 ft 50 fL 6.1/4 i" Sdr21 pvc
3449 16:INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Como,State,Variance,etc) ft• f, in.
3.Well Use(check well use): ft fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 24 ft- bentonite pour
Monitoring pRecovery ft. fL
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING'LOG'attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain s' etc
0 ft- 40 ft- soil
4.Date Well(s)Completed:2/9/2021 Well ID# ft• ft. soil/sandrock.
5a.Well Location: 40 ft 745 ft blue granite
Jim Hopkins ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Lorenza Nelson Rd ft. ft
Physical Address,City,and Zip ft. ft. g�n9
Stokes 21•REMARKS
County Parcel Identification No.(PIN) S3�Ci' �►Y�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22..Certifica(tiion:
N W , Q- \ -'gftuAM ) , . 2/24/2021
6.Is(are)the wel(s)(3Permanent or Temporary Sign tune 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 ONo with 15A NCAC 01C.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 ofthis 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: 745 (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: 165 (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 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) 4 Method of test: Sight 24c.For Water Supply&Iniection Wells: In addition to sending the fora[to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 21 Oz completion of well construction io 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