GW1-2021-07605_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Raymond Brown 14:WATER ZONES
FROM TO DESCREMON
Well Contractor Name
280 ft• 285 ft.
2312 390 ft• 392 ft.
NC Well Contractor Certification Number ..15 OUTER CASING fdi•rmulti�a9M we0s'OR LINER'if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER TffiCKNESS MATERIAL
0 ft- 137 ft' 6.1/4 in Sdr21 pvc
Company Name
3423 "16.INNER CASING OR TusING 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.) ft ft. in.
3.Well Use(check well use): ft. ft in.
r 17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 1s:GROUT
_' 'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft, bentonite pour
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
=19::SAND/GRAVEL PACK if a Iicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ®ITracer 20.DRII,�LINGLOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness6 soittrock type,grain size,etc.)
0 ft. 10 ft. soil
4.Date Well(s)Completed:01/18/2021 Well ID# 10 ft' 36 ft' Sandrock
5a.Well Location: 's ft 75 ft. blue ranite
75 ft. 110 ft, Sandrock
Facility/Owner Name Facility tD#(if applicable) 110 ft- 425 ft. bluegranite
1625 Hall Rd ft. ft.
Physical Address,City,and Zip ft ft. I
Stokes
21 REMARKS_., S '
5e�i�o
County Parcel Identification No.(PIN) „atzo�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ceertifica
N W -- :_ l 01/28/2021
6.Is(are)the well(s)[I Permanent 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: E]Yes or MNo 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#11 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: 425 (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 top of casing: 140 (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 Injection 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&Injection 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: 18oz 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