GW1-2021-00618_Well Construction - GW1_20211222

�:�;� Print •orm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Raymond Brown 111 14 WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 250 ft- 252 ft
2313
300 f, 302 ft
NC Well Contractor Certification Number 15.OUTER CASING for molti::L dwells OR LINER'if a"!!cable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 1 58 ft 61/4 in. sd21 pvc
Company Name
3593 16.INNER CASING OR TUBING eotherm&dosed-loop)
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: -17 SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g, ft in.
htdustrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL chips pour
Monitoring p Recovery ft. ft
Injection Well:
ft. ft
Aquifer Recharge E3 Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20J DRILLING LOG`attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00thcr(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soiuiock type,grain size,etc.
0 ft. 28 ft soil
4.Date Well(s)Completed: 1 0/26/21 Well ID# 28 ft. 50 ft' sandrock
5a.Well Location: 50 ft• 325 % granite
Wendy Owwens ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft i_ f
1067 Pleasant View Church Rd fc. ft
Physical Address,City,and Zip ft. ft
Stokes 11.REMARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tattlong is sufficient) 22.Certification:
N W &•qr 1// 10/26/21
6.Is(are)the well(s)13Permanent or OTemporary Signature ilfCertified 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: Dyes or ONo with ISA NCAC 01C.0100 or ISA 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 1 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: 325 (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 2@I00) construction to the following:
10.Static water level below top of casing:66 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service C i enter,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: j
(Le.auger,rotary,cable,direct push,etc.)
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 56 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: 18oz completion of well construction to the county health department of the county
where constructed. hI
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resoureesi Revised 2-22-2016