GW1-2021-07574_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
205 ft• 206 fL
2313
k. ft.
NC Well Contractor Certification Number ;45 OUTER;CASING foi multi cased wells)OR LINER ifs livable
Raymond Brown well Company, Inc FROM TO DIAMETER TRICI S MATERIAL
0 ft. 66 fl 6.1/4 1" sdr21 pvc
Company Name
.3444 ,Y6.INNER GASINGAR;TUBING `eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) k. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: FROM'SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) it. ft. in•
Industrial/Commercial Residential Water Supply(shared) 18:GROUT
.1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 fL bentonite pour
Monitoring DRecovery k. fL
Injection Well:
ft. fL
Aquifer Recharge E3Groundwater Remediation
19,SAND/GRAVEL PACK if appilcable '
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. fL
Experimental Technology Subsidence Control k. fL
Geothermal(Closed Loop) U3Tracer 20.DRILLING'LOG attach additional sheets,if necessary),
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 ft• 6 It. soil
4.Date Well(s)Completed: 1/30/2021 Well ID# 6 ft. 60 fL soil/sandrock
5a.Well Location: eo ft. 305 ft- blue ranite
Terri Sweat ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1247 Harris Rd ft. fL g\fig
Physical Address,City,and Zip ft. ft. 40
Stokes 21.REMARKS ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
N W `R- C - `f�)c 1 I 2/22/2021
6.Is(are)the well(s)�IPermanent 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: E3Yes or ONo 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#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: 305 (fl) 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 top of casing: 15 (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) 3 Method of test: Sight 24c.For Water Supply At 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: 16 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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