GW1-2021-00604_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r
Raymond Brown III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
285 ft. 287 ft.
2313
483 ft 484 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 88 ft. 6 1/4 in• sd21 pvc
Company Name :
3472 16.INNER CASING OR TUBING(geothermal
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL I In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL fL
Industrial/Commercial U311esidential Water Supply(shared) 18.GROUT
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. chips pour
Monitoring 3 Recovery ft. fL
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19..SAND/GRAVEL-PACK iLa livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coohn Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type rain siz etc
0 ft- 32 ft- soil
4.Date Well(s)Completed: 10/13/21 Well ID# 32 ft. 58 n' sandrock
Sa.Well Location: sa ft. 525 ft. granite
Jesse Simmons ft. ft. �=
Facility/Owner Name Facility ID#(if applicable) ft. ft. '
1107 JC Cox Rd Westfield, NC 27053 rt. rL 2
Physical Address,City,and Zip ft. fL
Stokes _21.REMARKS �•
County Parcel Identification No.(PIN) T
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N ``' 10/13/2021
6.Is(are)the wells)(3Permanent or E3Temporary Signature ertified 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 I 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: 525 (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 1Q100D 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
13a.Yield(gpm) 10 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: 25oz completion of well construction to the county health department of the county
where constructed. f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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