GW1-2021-00617_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brownl l l 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 480 rt• 481 ft.
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. 7D ft. 1 61/4 1O sda21 pvc
Company Name
36�3 ,16.INNERCASINGORTusING eotherinalclosed-loop)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R• ft. In.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17..SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g g, in.
Industrial/Commercial Residential Water Supply(shared)
18 GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pour
Monitoring Recovery ft. fa
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.'SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain s' etc)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks)
0 ft. g ft- Clay
4.Date Well(s)Completed: 12/3/21 Well ID# g ft. 60 ft. Sand rock
5a.Well Location: 80 ft. 525 It- Granite
Sam Hunter ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. D
Bunker Hill Road
Physical Address,City,and Zip ft. ft � r
Stokes 21.REMARKS + h.
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.Certification:
N W g`
� .12/3/21
6.Is(are)the well(s)f3Permanent or E3Temporary Signature bTCertified 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: E3Yes or XOj No with 15A NCAC 01C.0100 or 15A NCAC 01C.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#11 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: 525 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 t@200'and 1Q100D construction to the following:
10.Static water level below top of casing: 52 (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 Injection 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 C'enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: sight 24c.For Water Supply&Injection'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: i 1/zlb 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
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