GW1-2021-00623_Well Construction - GW1_20211222

.Paint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brownlll 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
880 fit• 705 fL I
2313
k. ft.
NC Well Contractor Certification Number 15.OUTER.CASING for multi-;6sed',weH§ OR LINER if a"licable
Raymond Brown well Company, Inc FROM TO DIAMETER I THICKNESS MATERIAL.
0 ft. 1 35 ft 61/4 I in. sd2l Pvc
Company Name
35.59 ;16.INNER:CASING'OR:TUBING eothr`m eal;closed-loo '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc) ft. ft. In.
3.Well Use(check well use): fit. tt. in.
17.
Water Supply Well: FROM SCREEN.TO DIAMETER I SLOTSIZEJ THICKNESS I MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft. in.
Industrial/Commercial Residential Water Supply(shared) &GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, PO ft. Hole Plug Pour
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3 Groundwater Remediation
t19.SAND/GRAVEL PACK Of applieable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology ®ISubsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer -20:DRILLINGLOG attach additional sheets`if hecessa
Geothermal (Heating/Cooling Retum Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillreck type,grain size,etc
0 ft. 10 ft* Red Clay
4.Date Well(s)Completed:8/26/21 Well ID# 10 ft. 30 ft. Send rock
5a.Well Location: 30 ft. 705 ft- Blue Granite
Sam Hooker ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft
1229 Hall Rd Westfield ft. ft. DEC
Physical Address,City,and Zip ft. ft.
Stokes 21 REMARKS shum
MPVRWTM PP,()Cf"M
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 MP/yVd �� /)1 8/26/21
6.Is(are)the well(s)>3Permanent or Temporary Signature 61Certified 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: []Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f 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: 705 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 50 (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 Infection 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.) tl
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) 25 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: eoz completion of well construction to, the county health department of the county
where constructed. GI
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016