GW1-2022-04655_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brownl II 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2313 141 ft, 143 ft-
394 ft. 395 ft
NC Well Contractor Certification Number 15.OUTER CASING formalti-cased wells OR LINER if a 6cable
Raymond Brown well Company, Inc FROM TO DIAMETER! THICKNESS MATERIAL
0 fL 153 ft 61/4 1 in- sd21 pvc
Company Name
3422 ;16.INNER CASING OR TUBING' eiithermalclosed•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: FROM
SCREEN A
FROM TO DIAMETER; SLOT SIZE THICKNESS MATERII,
Agricultural E)Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ;n
Industrial/Commercial E3Residential Water Supply(shared)
18.GROUT '
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 25 ft. Cement ! Cement Truck
Monitoring Recovery ft. ft.
Injection Well: ft
Aquifer Recharge ft. ft.
Groundwater Remediation 19.SAND/GRAVEL P if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20;DRILLING""LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
0 ft. 90 ft soil
4.Date Wells Completed:2/10/21 Well ID# g0 ft. 145 ft
()Co cop SoiOsand rock
5a.Well Location: 14e ft. 425 ft. Red Shell
Lori Cordial rt. ft T,
Facility/Owner Name Facility ID#(if applicable) ft. ft
1784 Rosebud ft. ft MAY 12 2022
Physical Address,City,and Zip ft
Stokes :21.REMARKS."
Unk
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
N W &az� 2/10/21
6.Is(are)the wells)(31'ermanent or OTemporary Signature dfCertified 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: E3Yes or MNo with 15A NCAC 01C.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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (fW 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3Q200'and 1Q100� construction to the following:
10.Static water level below top of casing: 66 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
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
i f
13a.Yield(gpm) 4 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: Chlorine Amount: 18oz completion of well construction t the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources l Revised 2-22-2016