GW1-2022-04679_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III M WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 375 ft. 400
ft. 0 ft. I
NC Well Contractor Certification Number p
15.0UTER CASING.for na i Cwkd'wens OR LINER if a 7fcable
Raymond Brown well Company, Inc FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 ft 77 ft- 61/4 1 ra sd21 pvc
mP Y
3616 :16:INNER-CAsl1YG OR'TU$ING eothetmal closed-loo"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits li.e.UIC,Comity,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft• ft. in.
„
Water Supply Well: 17.SCREENFROM TO DIAMETER SI.OTSIZE THICKNESS MATERIAL
Agricultural [3MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft. in
Industrial/Commercial DResidential Water Supply(shared) if1.GROUT
Irrr ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL Hole Plug Pour
Monitoring _ Recovery ft. ft.
Injection Well: &
Aquifer Recharge DGroundwater Remediation
19 SAND/GRAVEL PACK. applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Storrawater Drainage fL ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attachaddltional sheets if necessary)
Geothermal LHeatin oLUR Return) tither(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,solurock type,grain sae,etc.
0 ft- 20 ft- Red Clay
4.Date Well(s)Completed: 1/28/22 Well ID# 20 It. 72 ft. Sand Rock
5a.Well Location: n fL 425 ft- Blue Granite i
Michael Hargett fL ft.
Facility/Owner Name Facility ID#(ifappGeable) ft. ft.
ag9I Volunteer iej A. It. P►t>ce,emertg Lino
Physical
rAddress,City,and Zip ft, ft.
5!✓/�et5 21:REI4IARKS . , , ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N W �y 1/28/22
6.Is(are)the well(s)OPermanent or [iTemporary SignaturbfofCertified well Contractor Date
By signing this form,1 hereby certify that the»ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or J@No with 15A NCAC 02C.0100 or 15A NCAG 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 detafls:
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: SUBMMAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft) 24a. For An Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing:55 (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 (fD.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of thus form within 30 days of completion of well
12.Well construction method:
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) 3 Method of test: sight 24c.For Water SunDly&Infection Wells: In addition to sending the form to
136.Disinfection type: Chlorine
the address(es) above, also submit one copy of this form within 30 days of
Amount: tsoz 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 f Revised 2-22-2016