GW1-2021-07578_Well Construction - GW1_20210903

Prim Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCR[P,TION
Well Contractor Name 330 k• 332 IL
2313
k. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 fL 6.1/4 in. sdr21 pvc
Company Name
3412 16:INNER CAsuvG;oR TusINc iothermal'elosea-loop).
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): fL ft. in.
Water Supply Well: ;17::SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public % ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in..
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METAOD&AMOUNT
Non-Water Supply Well: 0 ft. 23 ft, bentonite pour
Monitoring .Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND)GRAVEL.PACK'if.a livable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage k. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLINGbLOG attach additional sheets if necessary)
Geothermal eatin ooling Return Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soivmck type,grain six etc.
0 ft. 40 ft soil ,
4.Date Well(s)Completed: 12/18/2020 Well ID# 40 ft. 65 ft. soil/sandrock
5a.Well Location: ss ft. 365 ft- blue granite
Steven Turrentine ft. fL
Facility/Owner Name Facility ID#(if applicable)
ft. fL
2544 Flatrock Rd ft. ft S Vn
Physical Address,City,and Zip ft. It. Q(o
Stokes 21.REMARKS r3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Ce rca' n:
N w 3/01/2021
6.Is(are)the well(s)OPermanent or Temporary Signature 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: 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: 365 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi[jerent(example-3Q200'and 2(a3100D construction to the following:
10.Static water level below top of casing:45 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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:
(Le.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) 45 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: �� 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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