GW1-2022-04632_Well Construction - GW1_20220512

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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
2313 160 ft• 162 ft,
ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING(for multitased'wells OR LINER if a lica6le
Raymond Brown well Company, Inc FROM TO DIAMETER' THICKNESS MATERIAL
0 fi. 57 It. 6114 f 'in' sd21 pvc
Company Name '
PRW L2�21�2�49 16.INNER CASING OR TusING eothermal dosed-loo
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
Agricultural DMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft, ft.
Industrial/Commercial E3Residential Water Supply(shared) ,18.GROUT
- Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, Chips Pour
Monitoring Recovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19:'SAND/GRAVELPACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test E3 Stormwater Drainage
Experimental Technology D Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG:attach additional sheets if necessary)
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock rain s' etc.)
p ft. 30 ft Soil
4.Date Well(s)Completed:2/14/22 Well ID# 30 ft. 50 ft. Sand Rock
5a.Well Location: 50 ft. 525 ft. Bieu Granite
Linda Davis ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. FL
5139 NC 268 ft. ft
Physical Address,City,and Zip ft. ft. DVVW80G
-S/✓�I y L REMARKS -
County 7 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 /0
J�� //1 2/14/22
6.Is(are)the well(s)(3Permanent or OTemporary Signature ofCertified 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 I5A 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 an 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-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: 525 (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: 60 (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 lniection 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: 24oz completion of well construction to 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