GW1-2022-04747_Well Construction - GW1_20220511

Pr:.irt FormN'
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 111 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
240 250
2313
NC Well Contractor Certification Number
IS.OUTER CASING for Tulti-cased*2 US)rL Rpa
Raymond Brown well Company, Inc FROM TO DIAMETER 1MATERIAL
0 ft. 78 ft' 61/4 in sd21 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2021049 FROM TO DIAMETER THICKNESS. MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. in.
3.Well Use(check well use): +:t ft. in.
Water Supply Well: 17.SCREEN:,FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:3Agricultural oMuniCipal/Public ft. ft in.
:]Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) —fL ft. in.
:]Industrial/Conunercial E3Residential Water Supply(shared) -18i GROUT
'1117gation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 ft hole plug Pour
:)Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
1-%Aquifer Recharge OGroundwater Remediation
L-3
L PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMELACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. ft. i
Geothermal(Closed Loop) [)Tracer 20'DRILLING LOG(attach addition I al sheets if inecessary)
Geothermal(Heating/Cooling Return) 0Other(explain under FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 20 fL Red Clay
4.Date Well(s)Completed: 12/29121 Well ID# 20 73 ft. Sand Rock
5a.Well Location: 73 ft. 265 ft- Blue Granite
Cherie Johnson ft. ft.I
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
2704 Griffin Rd ft. ft.
Physical Address,City,and Zip ft. ft.
Forsyth 21.REMARKS
RAY '!
County Parcel Identification No.(PIN)
k16DMP4bW PrOC664ing Unk
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification-
N W 12/29/21
6.Is(are)the well(s)OPermanent or [3Temporary Signature of 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 MNo 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 ofthis record has been provided to the i 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 Ito 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: 265 (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: 54
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Ce4ter,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
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service 6nter,Raleigh,NC 27699-1636
1
13a.Yield(gpm) 15 Method of test: sight 24c.For Water Supply&Iniecti6n Wells: In addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 8oz completion of well construction to thel county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016