GW1-2021-00467_Well Construction - GW1_20211222

P,int Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Raymond Brown III 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. 90 ft. k
2313 ft ft l
NC Well Contractor Certification Number "15:OUTER CASING for multitased wels OR LINER ifs ticatile -
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS I MATERIAL
0 f 1 62 ft 61/4 1°' sd21 pvc
Company Name
4556WELN21 ,.�16i INNER CASINGORTUBING eothermaldosed-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. fa in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft
Industrial/Commercial Residential Water Supply(shared)
18I GROUT
_l Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• hole plug pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
[Aquifer
ifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK'if a livable `
ifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test OStormwater Drainageerimental Technology Subsidence Controlthermal(Closed Loop) Tracer 20.DRILLING LOG attach>additionil sheets ifnecessathermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack e, in size,etc.
0 ft. 20 ft red day
4.Date Well(s)Completed:5/21/2021 Well ID# 20 ft. 57 ft sandrock'
5a.Well Location: sr ft 105 ft- blue granite
Jessica Werner
Facility/Owner Name Facility ID#(if applicable) ft. ft. r
3705 Russell Rd Graham, NC 27253 ft. ft
Physical Address,City,and Zip ft. ft DEC 1
14181118tICe 21.REMARKS
County Parcel Identification No.(PIN) 1Y f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 1-2021
/V14 C M C &Ldw
6.Is(are)the well(s)OPermanent or Temporary Signature of Certi d ell 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: E3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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
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9.Total well depth below land surface: 105 (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@1001 construction to the following:
10.Static water level below top of casing:26 (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. 6 (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:
(Le.auger,rotary,cable,direct push,etc.) P
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&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: HTH Amount: boz 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
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