GW1-2023-02403_Well Construction - GW1_20230404

Print Form__,` _
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown IV -14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3308
300 ft. 302 ft.
I i
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING foi•multi cased'Wells OR LINER if a Gcable
Raymond Brown well Company, Inc FROM TO DIAl11ETER'� THICKNESS MATER Z
0 ft 126 ft- 6114 I 1° sdr2l pvc
Company Name ,16'INNER_CASING OR TUBING.(geothermal closed-loop)
2.Well Construction Permit#: PRW L2O21 O 1599 FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. j in.
9T SCREEN'
Water Supply Well: ;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public ft. ft. in.
_. Geothermal(Heating/Cooling Supply) iX Residential Water Supply(single) ft. ft. in.
lndustrial/Commercial OResidential Water Supply(shared) 118.GROUT.'
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Cement Truck
Monitoring O Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge I3Groundwater Remediation
_ 19'SAND/GRAVEL-PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IOStormwater Drainage ft. ft.
Experimental Technology [I Subsidence Control ft. ft.
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hordness,soi0rock e, rain size,etc
—;Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks)
0 ft. 48 ft. Soil
4.Date Wells Completed:311/22 Well ID# 48 ft. 120 ft
()Com p Sand Rock
5a.Well Location: 120 ft. 425 ft- Granite
Natalie Baro ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. fL
863 Maranon Way ft. ft. - J
Physical Address,City,and Zip ft. ft t l i'._'::.,...•;':l ;� .,.; t r
Surry 21:REMARKS'.;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification:
N W Iz G I /1,/ 3/1/22
6.Is(are)the well(s)OPermanent or [ITemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature ofthe 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:
S.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: 425 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdffferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:20 (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:
(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) 4 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: 20Oz completion of well construction to 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