GW1-2021-07618_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
194 ft• 196 ft.
2313
ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING for multi-cased wells'OR LINER' f a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 7$ ft. 1 6.1/4, in Sdr21 pvc
Company Name
16.INNER CASING OR TUBING,`eothermal dosed-loop)
pprw1202000173
2.WQII 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.
Water Supply Well: FR M TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural E)MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt. ft. iP•
Industrial/Commercial [)Residential Water Supply(shared) 18.GROUT '
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 44 ft. bentonite pour
Monitoring ',Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
`19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage
Experimental Technology D Subsidence Control
Geothermal(Closed Loop) ©)Tracer 20.DRILLING'LOG attach additional sheets if necessary)
Geothermal eating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soutrock type,grain size,etc
0 ft- 40 ft. soil
4.Date Well(s)Completed: 01/05/2021 Well ID# 40 ft. 68 ft. soil/sandrock
5a.Well Location: ea ft. 225 ft- bluegranite
Daniel Bolton
Facility/Owner Name Facility lD#(if applicable) ft. ft.
Noe
Possumtrot Rd.
Physical Address,City,and Zip ft. it. v�
furry '21:'REMARKS S
ego
County Parcel Identification No.(PIN) t10
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
to��30
(if well field,one lat/long is sufficient) 22.Certification:
N W — ,, C. -f MvAk \\• 01/18/2021
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: []Yes or E)No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 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 ifdi(jerent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing: 73 (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,l Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 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: is 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