GW1-2022-04672_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2312 985 ft oq2ft. k
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING' for multi-cased.wells OR LINER(if a tit6
Raymond Brown well Company, Inc FROM TO DIAMETER; THICKNESS ATERIAI
Company Name 0 ft f" 6.1/4 I 'in Sdr21 pvc,
33.I G 16.INNER CA G OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1 V FROM TO DIAMETER THICKNESS MATFRiAr
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. '°•
3.Well Use(check well use): ft. ft.
17 SCREEN -
WaterSupplyWell FROM To DIAMETER: SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft' 4 in.
Geothermal(Heating/Cooling Supply) X[®I,�Residential Water Supply(single) ft ft. in
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft ft.
Monitoring DRecovery fr. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
'19ISAND/GRA1tEL PACK'if applictble '
'.Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test j Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. fa
Geothermal(Closed Loop) OTracer 20.DRILLING-LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) FROM I TO DESCREMON color,hardness,soil/mck type,gnin she,em
300 ft. 1025 ft- Granite
4.Date Well(s)Completed: 3/9/2020 Well ID# ft. ft.
5a.Well Location: ft ft.
1692 Power Dam Rd ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 2U2
Bobby Dellinger ft. ft. Una
Physical Address,City,and Zip ft. ft.
Stokes 21.REM RKS'
County Parcel Identification No.(PIN) / /
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one 1at(long is sufficient) 22.Certification:
e
N W
6.Is(are)the well(s)OPermanent or 1ITemporary Signature(ACertified 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: [3Yes or X®No 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 Ito provide additional well site details or well
construction,only I 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: 1025 ft
P ( ) 24a. For All Wells: Submit thisfonn within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of easing: 55 (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: (in.) 24b.For Injection 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.)
i
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&Injection Wells: In addition to sending the form to
the address(es) above, also submii one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 25 Oz 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