GW1-2022-04648_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
580 ft. ft.
2313 o ft. o ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER If a icable
Raymond Brown well Company, Inc FROM TO DIAMETER' THICKNESS MATERIAL
Company Name 0 fL 55 It. 61/4 in• sd21 live
PRW L202103626 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1Z SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) @, ft.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
I Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. /�O/e /d�' oar
Monitoring pRecovery
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 ®IStormwater Drainage ft. ft.
Experimental Technology EISubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)
Geothermal(Heating/Cooling Coolin Return) El Other(explain under#21 Remarks)
0 k• 20 fL Red Clay
4.Date Well(s)Completed: 3/25/22 Well ID# 20 ft. 50 ft. Sand Rock
5a.Well Location: so R• 625 ft- Blue Granite
Angela Barber ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
677 Miller Gap Rd ft. ft.
Physical Address,City,and Zip ft. ft
Surry 21.REMARKS Ming Unit
County Parcel Identification No.(PIN) QW w 8 W
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N W / , ,,qd / 3/25/22
6.Is(are)the well(s)t3Permanent or OTemporary Signature Wff Certified 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 MNo 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: 625 00 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100D construction to the following:
10.Static water level below top of casing: 50 (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
I
13a.Yield(gpm) 1'5 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: 16oz completion of well construction to kthe 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