_Well Construction - GW1_20230327 (36)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
ii
Raymond Brown 111 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
150 ft. ft
2313 o ft. 0 ft.
NC Well Contractor Certification Number 15:OUTER CASING for multi cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 76 fi 1 61/4 !in, sd21 Pvc
Company Name
22-02-WNHR-0�6$$ 16:INNER CASING ORTusING eotbermalclosed-moo -
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATF.RrAi.
List all applicable well construction permits(i.e.UIC,Comity,State,Parlance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public M ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 7T8.GROUT.
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. PO ft. Cement Pour
Monitoring r Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge IDGroundwater Remediation
:'19'SAND/GRAVEL PACK ifa' licbble .
Aquifer Storage and Recovery I�Salinity Barrier FROM TO MATERIAL EM PLACEMENT METHOD
Aquifer Test IOStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer :.20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION(color,hardness,soil/rock e, m size,etc.
BGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft- 20 ft, Red Clay
4.Date Well(s)Completed:4/5/22 Well ID# 20 ft. 71 ft. Sand Rock
5a.Well Location: )i ft. 165 ft. Blue Granite
Debbie Crosley ft. ft. =- =
Facility/Owner Name Facility ID#(if applicable) ft. ft. D O F
1343 Grant Haven Ct ft. ft.
Physical Address,City,and Zip ft. fL ]f,`C.i.w u:'C ^ ^.:jF�Url.*J
Guilford ..21.REMARKS ',:"` ' ' :`77.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W2ng�,� �'�_//l 4/5/22
6.Is(are)the well(s)OPermanent or [ITemporary Signature o ertified 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 -No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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-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: 165 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli Brent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:36 (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) 18 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: Chlorine Amount: 6Oz completion of well construction to Ithe 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