_Well Construction - GW1_20230327 (89)

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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
160 ft. %
2313
ft. ft.
NC Well Contractor Certification Number
'.'I&OUTER CASING ff0 multi
cased US)fR_L R&f:ipTiLab1e)'--
FROM TO rn-- THI= MATERIAL
Raymond Brown well Company, Inc
0 ft- 107 1 ft- 1 6 1/4 1In, dr2l Pvc
Company Name
16.INNER CASING-ORTUBING(geother al closed-loop)
2.Well Construction Permit#: 0650 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.
�517�SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMimicipal/Public ft. ft. in.
�)Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• ft. in.
:)Industrial/Commercial D Residential Water Supply(shared) '48.GROUT-
�Wmation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Hole Plug Pour
DMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge D Groundwater Remediation 19.,SAND/GRAVEL PACK if appli6able)
D -
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test 0 Stormwater Drainage ft. ft.
DExperimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer ,.20.DRILLING LOG(atwta h Additional sheets if necessary).
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type,gmin size,etc.)
0 ft- 40 ft- Red Clay
.
4.Date Well(s)Completed; 7/14/22 Well ID# 40 ft. 102 ft Sand Rock
5a.Well Location: 102 185 ft Blue Granite
Margaret Roberts rt. ft ""- �--y�—
Facility/Owner Name Facility 1D#(if applicable) ft. ft. MAR 2 7 ,9:o23
1735 Fish Dam Creek Rd ft. ft.
Physical Address,City,and Zip ft. ft.
" .'-R5��
Wilkes
21-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
N W 7/14/22
6.Is(are)the wefl(s)oPermanent or [3Temporary Silinature oYCertified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: rlYes or MNo 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 af 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 I 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: 185 (It-) 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:35 (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 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) 30 Method of test: sight 24c.For Water Supply&Injection 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: 8oz completion of well construction to Ithe 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