GW1-2022-04760_Well Construction - GW1_20220511

Prim Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name I
580 k. p ft
2313
p ft. p ft
NC Well Contractor Certification Number
15.OUTER CASING for multi-eased wells OR LINER if
ft. B licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 48 61/4 1° sd21 pvc
Company Name
AP312230 16.INNER CASING OR TusING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) k. ft. In.
3.Well Use(check well use): k. ft. in.
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural [3Municipal/Public ft fL in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) k. ft in.'
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
hTi ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
Monitoring E3Rccovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG`attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc
0 ft 20 ft Red Clay
4.Date Well(s)Completed:2/15/22 Well ID# 20 ft. 41 ft Sand Rock
5a.Well Location: 41 ft. 625 ft- Blue Granite
Dean Shetler ft' ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
327 York Spann Rd ft. ft
Physical Address,City,and Zip ft. ft. MAY 1 1 2022
Iredell 21.REMARKS
rocavlafly urw
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 M'LG-,i1j /f/ 2/15/22
6.Is(are)the well(s)OPermanent or OTemporary ggnature bfCertified 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 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: 625 (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@100D construction to the following:
10.Static water level below top of casing: 51 (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 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) 3 Method of test: sight 24c.For Water Supply&Iniection 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: 7 'TH Amount: 8Oz completion of well construction to J� 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