GW1-2021-07635_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown ,14:WATERZONES
Well Contractor Name FROM TO DESCRIPTION
572 ft• 573 ft.
2313
ft. ft.
NC Well Contractor Certification Number 15 OUTER CASING for`iriultl-ased wens'OR LINER'' f a ""Ilcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name �+�A C 0 it. 70 ff 6.1/4' i" sdr21 pvc
WSMF-007462-2019 16.INNER CASING,ORTUBING 'eothermal'closed-too
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. It. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 47.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
jAgricultural E3Municipal/Public ift —
in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. iri•
Industrial/Commercial E3Residential Water Supply(shared)
18.GROUT.
N—. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 27 ft. bentonite pour
Monitoring 13Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation P-n19.'SAND/GRAVEL_PACK if a "licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology ®I Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG'attach additional sheets if.necess
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soiltrock type rains 0
0 ft. 60 ft. SOLI
4.Date Well(s)Completed:01/11/2021 Wen HW ft. ft. Sandrock
5a.Well Location: rA ft. 605 ft- bluegranite
Scott Bricker ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1840 Helton Rd ft. ft.
Physical Address,City,and Zip
Yaadkin 21.RENIARKS i k
County Parcel Identification No.(PIN) I® '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W -V-- C- �lAl��� 01/28/2021
6.Is(are)the well(s)13Permanent 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 I5A 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: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 c@r 200'and 2®100� construction to the following:
10.Static water level below top of casing: 65 (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 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) 7 Method of test: Sight 24c.For Water SuDDIv&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: 21Oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016