GW1-2021-00605_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown IV 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
5a Q ft. O5
3308 rL
ft. ft.
NC Well Contractor Certification Number -15.OUTER CASING for mulmased wells OR LINER if a likable
Raymond Brown well Company, Inc FROM TO DIAMETER THICICNEss MATERIAL
0 ft 82 ft• 61/4 1in' sd21 pvc
Company Name r�
352 7 ;16.INNER CASING OR TUBING eothet•mal closed-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. ft. in.
Water Supply Well: FROM 17.SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in•'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• ft. in.
Industrial/Commercial Residential Water Supply(shared) 75.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. bentonite!:
Monitoring [Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Lf applicable)
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRIPTION color,hardness,soil/rack e, rain s' etc.)
Geothermal(IIcatin Coolin Return) Other(explain under#21 Remarks)
0 ft. 15 ft soil
4.Date Well(s)Completed:6/30/21 Well ID# 15 ft. 75 ft. Sand rock
5a.Well Location: 75 ft• 605 ft- Red shell rock
Nathan Hagedorn ft. rt
Facility/Owner Name Facility ID#(if applicable) ft. ft. 4
1639 Brookcove Rd Walnut Cove ft. ft. 'E
Physical Address,City,and Zip ft. ft
Stokes 21.REMARKS ILI .� •.y,r..,,..
1 / „a
County Parcel Identification No.(PIN) Urvo
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W R,,,,~'4 / 6/30/21
6.Is(are)the well(s)oPermanent or ®ITemporary ignature bT Certified 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 C@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}veil 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: 605 (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:25 (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 Infection 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) 4 Method of test: sight 24c.For Water Supply&Infection 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: $Oz 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