GW1-2021-00516_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brownl II 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
280 ft- 300 ft.
2313
fL fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR L R ifs livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fL 70 tt. 61/4 in. sdr21 Pvc
Company Name
2�20!)62 `l6.INNER CASING OR TUBING` eothi:rmal dosed-loop)
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): fL ft. in.
SCREEN17.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) fL fL in.
Industrial/Commercial 0Residential Water Supply(shared) 18:GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Y0 ft. Hole Plug Pour
Monitoring Recovery ft. fa
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 03Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer .20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock e, rain size,eta
0 ft• 20 fL Red Clay
4.Date Well(s)Completed: 3112/21 Well ID# 20 rc' 65 ft. Sand rock
5a.Well Location: 65 ft• 325 fL Blue Granite
Keith Banner ft. ft. 1
Facility/Owner Name Facility to#(ifapplicable) ft. ft.
1580 Rural Hall Germanton Rd ft. ft. DEC 2
Physical Address,City,and Zip ft. ft.
Forsyth 21.REMARKS
County Parcel Identification No.(PIN) CSS
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W g2464nd Ill 3/12/21
6.Is(are)the well(s)13Permanent or Temporary Signature WCertified 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 ONo 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: 325 (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:42 (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: 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:
(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 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: 6Oz 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