GW1-2022-04669_Well Construction - GW1_20220512

RFint.Form -=
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES -
Well Contractor Name FROM TO I DESCRIPTION
2313 155
ft. fL
ft ft.
p
NC Well Contractor Certification Number 15.OUTER CASING for mufti-cased wells OR LINER if a licable .
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 140 tt• 6 1/4 I. in• sd21 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3686 FROM TO DIAIYD TER 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: 17.SCREEN
FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
:)Agricultural DMunicipal/Public fL ft. in:
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) fG ft. in
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Cement Truck Pour
Monitoring DRecovery ft, ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology DSubsidcnce Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRELLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin Return) ;Other(e lain under#21 Remarks) FROM T DESCRIPTION(color,hardness,soivrock a rain s' etc.
0 ft. 63 ft* Red Clay,
4.Date Wells)Completed: 3/28/22 Well ID# 83 ft. 132 ft* Sand Rock
5a.Well Location: 132 ft. 225 ft Blue Granite
Mack Bottoms fL rL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1215 Rock Rd ft, ft. MAY 1
Physical Address,City,and Zip ft. ft.
Stokes 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tattlong is sufficient) 22.Certification:
N w p6mvM0,14 // ) 3/28/22
6.Is(are)the well(s)OPermanent or OTemporary Signature hTCertified Well Connector Date
By signing this form,l 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 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: 225 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') 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
13a.Yield(gpm) 40 Method of test: sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type; HTH Amount: 6Oz completion of well construction to 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