GW1-2022-04686_Well Construction - GW1_20220512

P.rinf Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r ,
Raymond Brown III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
550 ft. 555 ft.
2313
p ft. 0 fL
NC Well Contractor Certification Number iva 15.OUTER CASING:for mulH�ased wells OR LINER if a l" ble
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 50 IL 61/4 in.
n sd21 pvc
Company Name L� tt
EH V V p21 06-02� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: f FROM TO DIAMETER 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 ft. ft. in•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in;
Industrial/Commercial DResidential Water Supply(shared) '18.GROUT
1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ca. a ft. Chips Pour
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19;SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®I Stormwater Drainage tt. fI-
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG'attach additional sheets if necessa
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,aardness,soil/rock type rain size,etc.
0 ft. 21 ft. Soil
4.Date Well(s)Completed: 1/6/22 Well ID# 21 ft. 42 ft. Sand Rock
5a.Well Location: ,Z ft. 625 lt- Red Shale
Douglas Burke ft. ft. L"
Facility/Owner Name Facility ID#(if applicable) ft. ft.
292 Gibson Rd rt. ft
Physical Address,City,and Zip ft. ft. NWORMO- foo Unk
Rockingham 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latflong is sufficient) 22.Certification:
N w �� /l� 1/6/22
6.Is(are)the well(s)oPermanent or OITemporary Signature�kCertified 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• E3Yes or E)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 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: 625 (ft-) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 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) 5 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:r` Amount: 78Oz 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