GW1-2022-04644_Well Construction - GW1_20220512

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 qgp
p k. p fL
NC Well Contractor Certification Number 75.OUTER CASING for multi-cased wells OR LINER if a' livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
p ft. 65 It' 61/4 N in. sd21 pvc
Company Name
PR V A V L202 �22n77 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.U1C,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): k. ft. in.
17.SCREEN
Water Supply Well: '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural C)MunicipaVNblic k. ft. in:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) k. ft. in.
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT
rrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt 20 ft Hole Plug Pour
Monitoring EIRecovery ft. ft.
Injection Well:
ft. ft.
.Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVELPACK(if a livable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®I Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control k. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets it necessary)
Geothermal(Heating/Cooling Return) E3 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
0 k 20 IL Red Clay
4.Date Well(s)Completed:3/22/22 Well ID# 20 ft. 60 ft. Sand Rock
5a.Well Location: so k• 525 ft. Blue Granite
Anna Cromer ft. ft. RECEIVED
Facility/Owner Name Facility ID#(if applicable) ft. ft
2017 Holly Springs Rd ft. ft
Physical Address,City,and Zip ft. ft. 111folpubtion PrC1^Oi4mg LIM
Surry 21.REMARKS DwasoG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22.Certification:
N W 2a4ZL //( 3/22/22
6.Is(are)the well(s)OPermanent or [ITemporary Signature 16fCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or MNo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.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 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 I 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: 525 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi[jerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 120 (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 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) 00 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' 16oz completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources: Revised 2-22-2016