GW1-2022-04649_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 DESCRHMON
2313 380 ft- 390 ft.
p k. p ft.
NC Well Contractor Certification Number 75..OUTER CASING fortnulti-cased'wells OR LINER'if a 'ticable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft72 ft- 61/4 1. In sd21 pvc
Company Name -16.INNER CASINGOR'TUBING eothermal closed-loop)
2.Well Construction Permit#:
PRWL202200237 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,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 []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• ft. in..
:]Industrial/Commercial [3Besidential Water Supply(shared) 18.GROUT
hTi atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. -Do ft. Cement Pour
:)Monitoring E3Recovery ft. tt
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
I9rSAND/GRAVEL PACK it applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. fa
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach'additionnl sheets it necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock tyrre in s' etc
0 ft. 20 fL Red Clay.
4.Date Well(s)Completed: 1/31/22 Well ED# 20 ft. 67 ft. Sand Rock
5a.Well Location: 87 ft. 405 it- Blue Granite
Charles Davis ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
157 Charlie Davis Ln ft. ft.
Physical Address,City,and Zip ft, ft
REMARKS p=062ing
County Parcel Identification No.(PIN) DWWBW
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 1/31/22
6.Is(are)the well(s)OPermanent or EITemporary Signature of Certified 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 XMNo with 15A 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 1 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: 405 (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@100') construction to the following:
10.Static water level below top of casing: 140 (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) 75 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submitt one copy of this form within 30 days of
13b.Disinfection type: �rJ+ Amount* 16°Z completion of well construction to 1'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