GW1-2021-07607_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
117 ft. 118 ft.
2313
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING for multt cased wells`OR LINER'if'a [icable '
Raymond Brown well Company, Inc FROM TO DLIMETER THICIQYESS MATERIAL
0 fL 70 ft 6.114 1n sdr21 pvc
Company Name 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.UIC,County,State,Variance,etc.) It. ft. in.
3.Well Use(check well use): ft. ft. in.
17
Water Supply Well: SCREEN
pP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential 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 fL 20 ft* bentonite pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
[Experimental
fer Recharge Groundwater Remediation
19-SAND/GRAVEL PACK if applicable)
fer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fer Test 13 Stormwater Drainage ft. ft.
Technology [@Subsidence Control ft. ft.
ermal(Closed Loop) Tracer 20.DRILLINGrLOG attach additional sheets if necess,ermal(Heating/Cooling Return) Other(explain under 921 Remarks FROM
To DESCRIPTION(rnlor,hardness,soturock a grain size,etc.)
0 ft g it. SOII
4.Date Well(s)Completed:2/2/2021 Well ID# g ft. 62 ft. Sandrock
5a.Well Location: 62 ft' 225 e' bluegranite
Calvin Covington ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Johnson Rd. ft. ft.
Physical Address,City,and Zip ft. ft. G`
Stokes 21.REMARKS O
County Parcel Identification No.(PK
cz'O 9-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce fieation•
N W 02/03/2021
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: [3Yes 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#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: 225 (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: 35 (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: 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) 25 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: 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