GW1-2022-04727_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
6
1.Well Contractor Information:
Raymond Brownl ll 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 160 ft. fa
0 ft. 0 ft.
NC Well Contractor Certification Number 15.OUTER CASING for mukitased!wells OR LINER .s livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 66 ft. 61/4 In' I sd21 pvc
Company Name e
2021�0�04J 16INNER GASINGOR:TUBING eothertnal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Parlance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [31viunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) IL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. . D fL Hole Plug Pour
Monitoring DRecovery ft, ft.
Injection Well: ft ft.
I—ILAquifer Recharge Groundwater Remediation
19.SANDlGRAVEL PACK(ifapplicable
Aquifer Storage and Recovery $alinity Barrier FROM TO MATERIALL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin Retum) t Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness soil/mck a grain size etc
0 ft• 20 ft, Red Clay',
4.Date Well(s)Completed:2/3/22 Well ID# 20 ft. 63 ft. Sand Rock
5a.Well Location: 63 ft. 205 ft. Blue granite
Lyle Loftin ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1570 Cook Rd ft. ft.
i RECEIVED
Physical Address,City,and Zip ft. ft
Davidson 21.REMARKS ;
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 � /// 3/11/22
6.Is(are)the well(s)f3Permanent or Temporary Signature o Certified 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 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: 205 (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@I00D construction to the following:
10.Static water level below top of casing:54 (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 m.
(� ) 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) 20 Method of test: sight 24c.For Water Supply&Iniecti n 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: $Oz 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