_Well Construction - GW1_20230327 (80)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown III ?'AC WATER°ZONES'
FROM TO DESCRIPTION
Well Contractor Name
NIA ft. ft.
2313 ft. ft.
I
NC Well Contractor Certification Number ,`%15:'OUTER CASING for multi=d'wells OR LINER if a licable
Raymond Brown well Company, Inc FROM TO DIAMETER TEE[( ESS MATERIAL
0 ft. 39 ft. 6114 in' sd21 pvc
Company Name
3651 >16:=INNER CASING OR TUBING eothermal closed-loop) - •
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. i
n.
3.Well Use(check well use): ft. ft. in.
RT E
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) jC Residential Water Supply(single) g, ft.
Industrial/Commercial fDResidential Water Supply(shared) ."183 GROUT "
—' hTi ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
Monitoring D Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation 19C(SAND/GRAVEL RACK if a "Ilca6le
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
RGeothermal(Closed Loop) DTracer :..20.DRILLING LOG attach additiorial.sheets.if necessa
Geothermal (Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type.grain s' etc
0 ft. 20 ft. Red Clay
4.Date Wells Completed:6/13/22 Well ID# 20 ft. 34 ft.
()Com p Sand Rock
5a.Well Location: 34 ft. 1005 fr• Blue Granite
Ismelda Munoz ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. t-
Old 52 Rd ft. ft. `
Physical Address,City,and Zip ft. fL 4rtQC•ii G:5«^l t�`I?'r_'=f% �Ir;i
Stokes ,2i;REMARIcs :
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 // 1 6/13/22
6.Is(are)the well(s)oPermanent or OTemporary Signature o 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: QYes or XINo 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 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: 1005 ft.
P ( ) 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: N/A (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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:
(Le.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) 0 Method of test: sight 24c.For Water Supply&Infection 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: eoZ completion of well construction to the 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