GW1-2021-00616_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brownlll 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 400 ft. 425 ft.
ft. fL
NC Well Contractor Certification Number :15.OUTER,CASING for;malti-casedwe Us)OR LINER if.a licable
Raymond Brown well Company, Inc FROM TO DIAMETER TIHCICNEss MATERIAL
0 IL 46 it- 61/4 1° sd,21 pvc
Company Name
3591 16.INNER CASING OR TUBING] eothermal;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 EEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in..
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft ,n
:)Industrial/commercial Residential Water Supply(shared)
187GROUT
1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We1L• 0 it- 20 ft. Hole Plug Pour
3 Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
9.ISAND/GRAVEL PACK if a Ilcable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3 Stormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) 13Tracer '20.DRILLING:LOG'attach additional sheets if.necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock type rain size,etc.
0 ft. 10 ft, Red Clay.
4.Date Well(s)Completed: 11/19/21 Well ID# 10 ft. 41 ft. sand rock
5a.Well Location: 41 ft. 425 ft. Blue Granite
Gary Bryant fL ft. f
Facility/Owner Name Facility ID#(if applicable) ft. ft. .
1375 E Old Phillips Rd ft. ft. 2 2 2021
Physical Address,City,and Zip ft. ft
Stokes 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N W � // ) - 11/19/21
6.Is(are)the well(s)oPermanent or ]Temporary Signature y5fCertified 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: [3Yes or ®No 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.
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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: 425 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:51 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
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13a.Yield(gpm) 5 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: 16az completion of well construction tol 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
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