_Well Construction - GW1_20230327 (73)

IF Print Form`
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
' Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2313 240 245 It. I
rt. rt.
NC Well Contractor Certification Number ";15:OUTER CASING(fd.multi cased wells OR LINER',if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS aATERIAL
Company Name
0 ft. 61 ft- 6.1/4 in 1 sdr21 pvc
t 16.INNER CASING OR TUBING, eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) I pResidential Water Supply(single) ft. ft. in•
Industrial/Commercial DResidential Water Supply(shared) -18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite chips pour
Monitoring ORecovery 0 ft. ft* cement truck
Injection Well: ft. ft.
- Aquifer Recharge 0Groundwater Remediation
19:SAND/GRAVEL PACK if applicable)'
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) I©ITracer '-20.DRILLING LOG attach additional sheets if necessary):'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type rain size,etc.)
0 ft. 9 ft. soil
4.Date Well(s)Completed:5/5/2021 Well ID# 9 ft. 50 ft. soil/sandrock
5a.Well Location: so ft. 265 ft- bluegranite ;"
Jerry Manuel rt. ft. -
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR 2 7 2023
Stanley Mabe Rd. fr. rt l�
Physical Address,City,and Zip ft. ft. in? i it •'•t,t ^i�L " '
Stokes ''21:REMARKS..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certl�ati
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6.Is(are)the well(s)oPermanent or I©ITemporary Signature ofCet�ified 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: i Yes orINo 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 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: 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@100D construction to the following:
10.Static water level below top of casing: 61 (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 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
13a.Yield(gpm) 100 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: Hth Amount: t4 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
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