GW1-2021-00608_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information: j
Raymond Brown III 14 WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
440 ft. 445 ft.
2313
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi�ased'wells ORLINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER III[ ESS MATERIAL
ft. ft in.
Company Name
3589 INNER CASING OR TUBING "eothermal dosed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) N/A ft. ft. i in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM REE TO DIAMETER, SLOT SIZE THICKNESS MATERIAL.
Municipal/Public ft ft in.
Agricultural �
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in,
Industrial/Commercial Residential Water Supply(shared) 18rGRO
Geothermal
UT-
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: N/A ft. ft
Monitoring C Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK if a licable "
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [)Tracer 20:DRILLING-LOG attach additional sheets if iietessa =
Geothermal(Heating/Cooling Return) E3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soi0rock type,grain size,etc
165 ft- 445 ft. Blue granite
4.Date Well(s)Completed: 10/20/21 Well ID#
ft. ft.
5a.Well Location:
Sarah Miller ft. ft
�. e_ y as,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ri
1093 Johnson Farm Rd Pilot Mtn ft rt -
Physical Address,City,and Zip ft. ft.
Stokes 21},REMARKS'
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County Parcel Identification No.(P]N) ( nr*ll Deeper
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W P/10/20/21
6.ls(are)the well(s)OPermanent or 1ITemporary Signature dWertified 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: K)Yes or E3No with 1 SA 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: 445 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3 200'and 2@100D 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 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.
(Le.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) 20 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. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources` Revised 2-22-2016