GW1-2022-04664_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brownlll 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 150 ft. 152 ft.
NC Well Contractor Certification Number '15.OUTER CASING(for malti cased wells OR LINER if a' livable ,
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 60 ft- 61/4 i in• sd21 pvc
Company Name 16.INNER CASING OR TUBING °eothermal closed-loop)
2.Well Construction Permit#: 3576 FROM TO DIAMETER I THICKNESS MATERU L
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. I in.
3.Well Use(check well use): k. It. I ' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) k. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Q tt. Chips Pour
Monitoring Recovery ft. ft.
Injection Well: k. 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 Subsidence Control k. ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG-attach additional-sheets it necessaryj
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 35 ft. Soil
4.Date Well(s)Completed: 12/28/21 Well ID# 35 ft. 73 ft. Sand Rock
5a.Well Location: n ft 805 ft. Granite
Les Campbill k ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY 12 2022
6600 NC Hwy 8 ft. ft.
Physical Address,City,and Zip k. ft. DWQIBOG
Stokes 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N w //1 12/28/21
6.Is(are)the well(s)13Permanent or Temporary Signature orCertified 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 ONo with 15A NCAC 02C.0100 or ISA 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 i'to provide additional well site details or well
construction,only I 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: 805 (fL) 24a. For All Wells: Submit this iform within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following: I
10.Static water level below top of casing:70 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
lI.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) 2 Method of test: sight 24c.For Water Supply&Iniecti in 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: completion completion of well construction to the county health department of the county
where constructed. I
a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016