GW1-2021-00625_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Raymond Brown 14.WATER ZONES
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Well Contractor Name FROM TO DESCRIPTION
221 R• 223 ft.
2313 '
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi cased!wells'OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER' THICKNESS MATERIAL
O ff• 33 ft• 6.1/4 i 1O sdr21 pvc
Company Name
3494 .46.INNER CASING.OR TUBING(geothermal closed-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
JAgricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
I Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
n lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• bentonite pour
Monitoring .Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Traeer 20.DRILLING LOG-attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) :Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiurock e, rain sic etc.
0 ft. g ft. SOII
4.Date Well(s)Completed: 5/8/2021 Well ID# g ft. P5 tt. sandrock
5a.Well Location: 25 ft. 525 ft- blue ranite
Jacob Bullins ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2101 Pitzer Rd ft. ft.
Physical Address,City,and Zip
ft. ft.
Stokes 21.REMARKS
County Parcel Identification No.(PIN) MOM M.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one W/long is sufficient) 22.Certification:
N W 90A fr''�
6.Is(are)the well(s)13Permanent or OTemporary Signature if Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E)No 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 I 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: 525 (fl-) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:80 (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 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:
(i.e.auger,rotary,cable,direct push,etc.)
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: t'S lb completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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