GW1-2022-04660_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: p
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 180 k• 200 ft.
p k. p ft.
NC Well Contractor Certification Number 15.OUTER CASING(formuki-cased wells OR LINER ifa livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERGll
p ft. 57 ft. 61/4 I in. sd2l pvc
Company Name
.36�$ 16.INNER CASING OR TUBING 'eothermal closed-loo
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) k. ft. In.
3.Well Use(check well use): k. ft. in.
Water Supply Well: 17.,SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public k. ft. in:
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
1 lndustriaucommercial Residential Water Supply(shared) 48 GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' R C) ft' Hole Plug Pour
Monitoring ;Recovery
Injection Well:
k. ft.
Aquifer Recharge 13 Groundwater Remediation
fleft ;19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [I Stormwater Drainage k. tt.
Experimental Technology E3 Subsidence Control k. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets,if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
0 ft. 20 ft, Red Clay
4.Date Well(s)Completed:2/4/22 Well ID# 20 ft. 52 ft. Sand Rock
5a.Well Location: 52 ft. 205 ft. Blue Granite
Michael Bennett n ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1
1258 Fred Merritt Rd k. ft. M
Physical Address,City,and Zip ft. ft.
Stokes 21.REMARKs
MR"Una
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W /I 12/4/22
6.Is(are)the well(s)(3Permanent or ®ITemporary Signature of 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: E]Yes or ONo 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 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 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: 205 (it•) 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 1@I00� construction to the following:
10.Static water level below top of casing:42 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) 50 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
,1 the address(es) above, also submit one copy of this form within 30 days of
/�13b.Disinfection type: �H Amount: 16°Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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