GW1-2021-00651_Well Construction - GW1_20211222

.P int o r.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
120 ft- 160 ft.
2313
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a 7icable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 113 ft- 61/4 1°' sdr21 pvc
Company Name
PRW L2�21 0.32�3 16.INNER CASING OR TUBING(geothermal 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): ft. ft. in.
Water Supply Well: 17.SCREEN
plt y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaVPublic fL ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
:J Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 51 ft /�
Monitoring C Recovery ft. ft. r'
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. fL
Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer .20.DRILLING.LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r3 Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc.
0 ft. 40 It- Red Clay
4.Date Well(s)Completed: 11/15/21 Well ID# 40 ft. 108 ft
Sand Rock
5a.Well Location: toe ft. 205 ft- granite
Kathleen Mueller fc. fc.
Facility/Owner Name Facility ID#(if applicable) ft. ft
132 Bumpy Trail Pilot Mountain ft. ft
Physical Address,City,and Zip ft. ft mje t'i� I3vii I
Surry 21.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.Certification:
N W gD��pvoyjd J>I 11/15/21
6.Is(are)the wlf(s)(3Permanent or Temporary Signature orCertified 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 ISA 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: SUBNUTTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 32 (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 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 coustruction 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) 15 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 tti 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