GW1-2021-00629_Well Construction - GW1_20211222

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� P.rint Foram
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. k
2313
k. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL.
0 ft. 55 ft 6.1/4 i° sdr21 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. k. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public k. ft. in.'
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.[
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 k• 20 ft chips pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAyEL-PACK if applicable)
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control k. ft.
Geothermal(Closed Loop) Tracer 20.DRILL-ING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION mlor,hardness,soil/rock type min size,etc.
0 k• 22 ft. soil
4.Date Well(s)Completed: 7/23/21 Well ID# 22 ft. 47 ft' sandrock
5a.Well Location: 47 ft. 1,425 f`• granite
John Morton e. r`•
Facility/Owner Name Facility ID#(if applicable) ft. It.
1035 Smith's Cemetary Rd. Lawsonville, NC ft. 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 lat/long is sufficient) 22.C fication:
N W C 7121
6.Is(are)the well(s)OPermanent or ®ITemporary Signa re of Certlied Well Contractor Da[
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: E]Yes 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: 1,425 (fC
P ) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00� construction to the following:
I
10.Static water level below top of casing: 30' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,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:
(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) 1/2 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: 30 completion of well construction to th'e county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Ik Revised 2-22-2016