GW1-2022-04678_Well Construction - GW1_20220512

f
tint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
E
Raymond Brown III 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name y
160 ft. 180 ft. f
2313
p ft. p ft.
NC Well Contractor Certification Number OUTER CASING for multi cased'wells OR:LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 106 it- 6114 In sdf21 pvc
Company Name
3638 16.INNER CASING OR-TUBING ebthermal'closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. k. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREENTO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft in.j
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) &GROUT
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. O ft. Hole Plug Pour
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
39:SAND/GRAVEL PACK"if applicable
A[Experimental
ifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ifer Test [3Stormwater Drainage ft. ft.
Technology 0Subsidence Controlthermal(Closed Loop) EITracer 20i:DRILLINGLOG attach additional sheets if,necessaFROM TO DESCRIPTION(color,hardness,soiUrock e, rain siz etc.thermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
0 it• 20 it• Red Clay'
4.Date Well(s)Completed: 12/28/21 Well ID# 20 it. 101 ft. Sand Rock
5a.Well Location: 101 it• 185 it• Blue Granite
Dee Spencer/Wanda Wall ft. ft. =
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2265 Wall Loop ft. ft MAY 12 2022
Physical Address,City,and Zip ft. ft.
Stokes .21.REMARKS 10
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N w fwy� /// 12/28/21
6.Is(are)the well(s)O-Permanent or EITemporary Signaturc+4fCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or EJNo 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 921 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-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: 185 (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@100') construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
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
J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 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 j Revised 2-22-2016