GW1-2021-00517_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 114.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
2313 464 ft. 565 ft.
ft. ft i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wef)s'OR LINER if a Hcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 1. it. 6.1/4 1° sdr21 pvc
Company Name (1
2019065 16.INNER CASING OR TUBING eothermal closed-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): ft. ft. in.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 23 ft. bentonite pour
Monitoring DRecovery 0 ft. ft* cement pour
Injection Well:
ft ft
Aquifer Recharge E3Groundwater Remediation
"19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardy soil/rock e, rain size,etc.)
Geothermal satin Coolin Return) Other(explain under#21 Remarks
0 ft. ft. soil
4.Date Well(s)Completed:8/18/21 Well ID# o ft. ft. soil/sandrock
5a.Well Location: 265 ft. 625 ft- blue ranite
Vernon Sheets ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. It.
140 Sheets Trt ft. IL
Physical Address,City,and Zip ft. ft.
Forsyth %21.,RENJARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce nation:
N W -- . C- ,l . 8/16/2021
6.Is(are)the well(s)f3Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.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-I 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: 360 (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@200'and 1@1001 construction to the following:
10.Static water level below top of casing: (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) 15 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: 20 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