GW1-2022-04724_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown IV 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
k. ft.
3308
k. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER`if a Qca61e
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MA7 FRSAi.
0 f1. 62 fi 6114 in sd21 pvc
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERUL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) k. it. in.
3.Well Use(check well use): k. it.17.
Water Supply Well: FROMCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) k• ft,
Industrial/Commercial [Residential Water Supply(shared) 718.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 62 ft Cement Pour
:11monitoring pRecovery ft. ft.
Injection Well:
k. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a'livable
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. it.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock rain size,etc.
Geothermal(Heating/Cooling Coolie Return) Other(explain under#21 Remarks)
N/A k• N/A ft.
4.Date Well(s)Completed:3122/22 Well ID# ft. ft.
ft, ft.
5a.Well Location:
Clarenda Stanley fL ft
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft.
NLCE
210 Hinshaw Shop Rd ft. ft
Physical Address,City,and Zip k ft. �i1 lOf1
Chatham .:21.REMARKS_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N w J /I/ 3/22/22
6.Is(are)the well(s)oPermanent or Temporary SignaturAbfCertified 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: RYes or I Wo 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 constntction 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-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: (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@100D construction to the following:
10.Static water level below top of casing: (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:
(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
i
13a.Yield(gpm) Method of test: sight 24c.For Water Supply&Infection 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: HTH 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 Revised 2-22-2016