GW1-2022-04680_Well Construction - GW1_20220512

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information: P
Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
2313 280 ft- 285 ft-
0 k. 0 ft.
NC Well Contractor Certification Number "15.OUTER CASING for TSUI cased>wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft 99 IL 61/4 1° sd21 pvc
Company Name
3638 16.3NNER'CASING OR TUBING eothermal clmed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Valiance,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 13MunicipaMblic ft. ft. in.'.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial iDResidential Water Supply(shared) 18 GROUT
'hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 30 ft Hole Plug Pour
Monitoring 13Recovery ft. ft.
Injection Well:
k. 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 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional'sheets if necessa
Geothermal(Heating/Cooling Coolin Return Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock e, rain s' etc.)
0 ft. 20 ft, Red Clay,
4.Date Well(s)Completed:2/2/22 Well ID# 20 ft. 94 ft. Sand Rock
5a.Well Location: sa ft 300 ft slue Granite
Dominick Goldston ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2177 Pilot Ct ft. ft. i
IMAY 1
Physical Address,City,and Zip ft. ft.
Ult
Randolph 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification: /
N W �/� 2/2/22
6.Is(are)the well(s)JIPermanent or Temporary !@nature oVCertified 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 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: 300 (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@100D construction to the following:
10.Static water level below top of casing:46 (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 Infection 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: P
(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) 10 Method of test: Sight 24c.For Water Supply&Injection 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: 14'H Amount• 16oz completion of well construction to Ithe county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016
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