GW1-2021-00640_Well Construction - GW1_20211222

Prant'Form�
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.(�Well Contractor Information:
`kGl\1 N��l/�V v {`C�U�V) 14.WATER ZONES
FROM TO DESCRIPTION
Well Contract r Name
582 ft- 563 ft.
�313 ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING for multi-cased wells OR LINER if a ticable
Raymond Brown well Company, Inc FROM TO DIAMETER TRICKINESS MATERIAL
0 ft 62 ft- 6 1/4 ' in. sdr21 pvc
Company Name
3572 16:INNER CASING OR TuIiING `eothermal dosed-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): fr. ft. in.
17.
WaSC
ter Supply Well: FROM REE M TO DIAETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p
Monitoring 13Recovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
49.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage tt. It.
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
425 ft- 625 fL bluegranite
4.Date Well(s)Completed:8/26/2021 Well ID# ft. ft.
5a.Well Location:
Isreal Lawson ft. ft. r
Facility/Owner Name FacilityID#(if applicable) ft. ft EC
1178 Hart Rd Lawsonville, NC 27022 rt. ft
Physical Address,City,and Zip ft, ft
Stokes 21.REMARKS tl
County Parcel Identification No.(PIN) Drill de per
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W C �cj 1 11 8/26/2021
6.Is(are)the well(s)1IPermanent or ®ITemporary Signature of Ce fled Weu 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 E3No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 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 toithe 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: 625 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For mutriple wells list all depths ifdii erent(example-3@200'and 2@I00) 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: 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.)
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) 8 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
Chlorine 19oz completion of well construction to the county P health department of the county
13b.Disinfection type: Amount: P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016