GW1-2021-00686_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
478 ft. 479 ft.
2313
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.wens OR LINER if a Gcable
Raymond Brown well Company, Inc FROM TO DIAI1tETER TffiCKNESS MATERIAL
Company Name 0 ft 95 ft 63.1/4 1 Sdr21 pvc
16.INNER CASING OR TUBING(geothermal closed-loop),Oco�^r�� `
2.Well Construction Permit#: V 42 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 in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL g.
_ Industrial/Commercial DResidential Water Supply(shared)
d8.GROUT
a Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 23 fL bentonite pour
Monitoring DRecovery o ft. ft* cement pour
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK[if tipplicible
-Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) I[�I,Tracer 20.DRILLING LOG attach additional sheets if necessary)
L Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 70 ft. soil
4.Date Well(s)Completed:7/15/2021 Well ID# 70 ft. 90 ft. soil/sandrock
5a.Well Location: 90 ft• 565 ft blue renite
Robert and Debrah Billings ft. ft. OEC 2 2 2021
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4798 White Plains Rd. ft. ft
Physical Address,City,and Zip f' ft
Wilkes 21.REMARKS,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the wetl(s)oPermanent or OTemporary Signature ofCqrtified Well Contrac or Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ®IC 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 1 GW-I 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: 565 (ft-) 24a. For All Wells: Submit this:form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200 and 2@100D construction to the following:
10.Static water level below top of casing:70 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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
13a.Yield(gpm) 1.5 Method of test: Sight 24c.For Water Supply&Injection 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: 17 completion of well construction to Ithe county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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