GW1-2021-00620_Well Construction - GW1_20211222

��.�Prrrl
i -
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brownl II 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
600 ft. ft. 4
2313 ft. ft.
NC Well Contractor Certification Number
15.OUTER.CASING for 7u116 cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER T>�cicrtESS MATERIAL
0 rt• N/A ft 61/4 1" sdr2l pvc
Company Name
3222 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,Coupy,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 DMunicipal/Public ft. ft. in.!
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
Industrial/Commercial 311esidential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. N/A ft.
Monitoring pRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 1.9.SAND/GRAVEL PACK if a`licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING'LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0
4.Date Well(s)Completed:4/23/19 Well ID#
5a.Well Location:
Jessica Shalton ft. ft.
Facility/Owner Name Facility m#(if applicable)
rr. ft.
1230 Early Lane ft. ft.
Physical Address,City,and Zip ft. %
Stokes 21.REMARKS
r, f�l`L'CC
County Parcel Identification No.(PIN) Q '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 4/23/19
6.Is(are)the well(s)(3Permanent or E3Temporary Signature ofkertified 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: Ryes or I INo 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.
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: 865 00 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths ifdi[ferent(example-3@200 and 1Q100� 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 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
(L
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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) 2 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: 8oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I� Revised 2-22-2016
I