GW1-2021-00624_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) i For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
298 ft• 299 ft.
2313
ft. ft.
NC Well Contractor Certification Number
15'OUTER CASING forrmulfi cased wells OR LINER ifs licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 105 ft- 6.1/4 j in. sdr21 pvc
35�5 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Cut all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural E3Municipal/Public ft IL in.,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in•
:)Industrial/Commercial DResidential 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
Injection Well:
ft. ft
[Aquifer
uifer Recharge (Groundwater Remediation
19.SAND/GRAVEL PACK Of a. licable
uifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test [I Stormwater Drainage ft. fterimental Technology Subsidence Control ft. ftthermal(Closed Loop) Tracer 20.DRILLING LOG.attach additional sheets if necessathermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM T8 DESCRIPTION(color,hardness,soil/rock e, rain size etc.)
0 ft. 80 ft 501)
4.Date Well(s)Completed: 5/13/2021 Well ID# 80 ft. 90 fL soil/sandrock
5a.Well Location: w ft. 425 ft blue ranite
James Parrish ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
3649 Piney Mtn Rd. ft. ft
Physical Address,City,and Zip ft. ft E L' 22021
Stokes 21.REMARKS
County Parcel Identification No.(PIN)
DArR Sf:CI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "ESS
(if well field,one IatAong is sufficient) 22.Certification:
N W S'-/ 3[3- l
6.Is(are)the well(s)OPermanent or OTemporary Signature oftCertified 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: E3Yes or ONo 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: 425 (ft) 24a. For All Wells: Submit this 1form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@1001 construction to the following:
I
10.Static water level below top of casing:60 (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: (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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C inter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Sight 24c.For Water Supply&Infection 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: 17Oz completion of well construction to I
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