GW1-2021-07623_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
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Raymond Brown 14.WATER ZONES
FROM ITO DESCRIPTION
Well Contractor Name
570 ft. 572 ft.
2312
ft. rt.
NC Well Contractor Certification Number 15'OUTER CASING for multi-cased wells OR LINER if a" IIcable
It•
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 43 6.1/4 in sdr21 pvc
Company Name beh080717-02 16.INNER CASING OR TUBING 'geothermal dosed-loop).
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable svell construction permits(i.e. UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
:)Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commcrcial Residential Water Supply(shared) 113:GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20' ft. bentonite pour
Monitoring p Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL:PACK f,a`licable 'r
Aquifer Storage and Recovery E3Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METR D '
Aquifer Test OStormwater Drainage
Experimental Technology D Subsidence Control
Geothermal(Closed Loop) 1OTracer 20:1111, RILLING 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. 10 ft. soil
4.Date Well(s)Completed: 12/29/2020 Well ID# 10 tt' 22 ft' soil/sandrock
5a.Well Location: 22 rt• 625 ft bluegranite
Maria Guadalupe Sierra
Facility/Owner Name Facility ID#(if applicable)
1119 Holly Springs Rd rc, ft.
Physical Address,City,and Zip ft. ft. Q�$5
Surry 21REMARKS., 10 G
County Parcel Identification No.(PIN) \r O O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W _ I ' 01/08/21
6.Is(are)the well(s)OPermanent or Temporary Signh ore of Certified Well Contractor, J� 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 E]No with 15A NCAC 02C.0100 or 15A NCAC 01C.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:
S.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 I 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: 625 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 50 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 Infection 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 ServiceCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: Sight 24c.For Water Supply&Infection 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: 1lb completion of well construction Ito the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc i es Revised 2-22-2016