GW1-2021-00569_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
121 ft- 122 ft.
2313
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 55 ft- 1 6.1/4 j in I sdr21 pvc
Company Name 7
O 172H 16.INNER CASING OR TUBING(geothermal 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: 17.SCREEN
FROM TO DIAMETER'. SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ROResidential Water Supply(single) fL ft. in.
Industrial/Commercial jDResidential Water Supply(shared) ;18.`GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 23 IL bentonite pour
Monitoring r Recovery 0 ft. ft* cement pour
Injection Well:
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sofll o k type,grain size,etc.)
0 ft. ft. soil
4.Date Well(s)Completed:8/5/21 Well ID# 0 ft' 45 ft. soil/sandrock
5a.Well Location: 45 ft. 185 ft blue granite
Cole Martin ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft I:E C 2 2 2021,
2289 Banner Whitehead Rd. ft. fL
Physical Address,City,and Zip ft. %
Randolph 21.REMARKS
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.C fie8' n:
N W 8/11/21
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or MNo with 15A NCAC 02C.0100 or ISA 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 ito 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: 185 (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@I00) construction to the following:
10.Static water level below top of casing:60 (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
i
13a.Yield(gpm) 15 Method of test: Sight 24c.For Water Sunoly&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: 18 completion of well construction tolthe county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources r Revised 2-22-2016