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HomeMy WebLinkAboutGW1-2022-04747_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