GW1-2022-04745_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Raymond Brown111 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
N/A ft. N/A ft.
2313
0 ft. 0 ft.
NC Well Contractor Certification Number 1$:OUTER CASING for multi-cased wells OR LINERi if:9 licatile
Raymond Brown well Company, Inc FROM TO DIAMETERS THICKNESS MATERIAL
0 ft. N/A ft 61/4 ,1° sd21 pvc
Company Name
ZOZZ003 ;16INNER'CASING OR TUBING cothermal closed•loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATE RIAL
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.
N.
Water Supply Well: FROM E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural E]Municipal/Public ft. % in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18 GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• N/A ft hole plug! Pour
Monitoring ;Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK"if a "licnble
Aquifer Storage and Recovery E)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets(ifnecessa
lGeothermal.(Heating/CoolingRetum) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rock e, rain size,etc.
ft. ft.
4.Date Well(s)Completed: 1/7/22 Well ID# ft. ft.
5a.Well Location: 625 ft. 1005 ft• blue granite
Debra Johnson ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7561 Hwy 65 ft. fr.
Physical Address,City,and Zip ft, ft.
IWL
Forsyth 21 REMARKS i
County Parcel Identification No.(I'M
nrmil Deeper
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N w , 1/7/2022
6.Is(are)the well(s)OPermanent or Temporary Signature ofCertified 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: []Yes or I JNo 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 921 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: 1005 (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@100) 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 (�m.
) 24b.For Injection 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
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13a.Yield(gpm) 0 Method of test: sight 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit bne copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 16Oz 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 Resourccsj Revised 2-22-2016
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