GW1-2022-04743_Well Construction - GW1_20220511

Prrl Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
u
Raymond Brownl II 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
625 ft- 685 ft
2313 ft. ft f
NC Well Contractor Certification Number 15.OUTER CASING for mahi-cased:wells OR LINER if a 6csbie
Raymond Brown well Company, Inc FROM TO DIAMETER TAICIINESS MATERIAL
0 ft 102 ft.
61/4 ( in• sdr11 pvc
Company Name
304959'1 16.INNER CASING OR TUBING' eothermal closed-loo
2.Well Construction Permit#: 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) rL ft, in.l
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. Hole Plug" Pour
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19dSAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology ®ISubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin C oling Return Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soil/rock type,gmia size,etc.)
0 ft. 20 ft, Red Clay,
4.Date Well(s)Completed: 1 1/27/20 Well ID# 20 ft. 97 ft. Sand Rock
5a.Well Location: sr ft. 745 ft. glue Granite
Max Maxwell ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5583 Pineview Dr Winston Salem
Physical Address,City,and Zip ft• ft kftmajilon Proems Unit
Forsyth 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification:
N w 11/27/20
6.Is(are)the well(s)oPermanent or Temporary Signature ofiVirtified Well Contractor , Date
By signing this form,I hereby certify that the welI(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes 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 I 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: 745 (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@700D construction to the following:
10.Static water level below top of casing:41 (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) 10 Method of test: sight 24c.For Water Supply&Iniecti pon 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: lsoz completion of well construction to!the county health department of the county
where constructed. E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016