GW1-2023-02428_Well Construction - GW1_20230404

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ryamond Brown III -14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
385 ft. ft.
2313
ft. fL
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
Company Name
0 fL 61 ft- 61/4 i i° sd21 pvc
FRWL2�22��934 46:'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. In.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: °17.SCREEN:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
:)Geothermal(Heating/Cooling Supply) Ix Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) ;18r.GROUT "
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft, 20 ft. Hole Plug Pour
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
,'79i`SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EIStormwater Drainage ft. ft.
Experimental Technology OSubsidcnce Control ft. fL
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain size,etc)
RGeothermal(Heatin Cooling Return) Other(explain under#21 Remarks)
0 ft. 20 IL Red Clay
4.Date Well(s)Completed:6/22/22 Well ID# 20 ft. 56 ft. Sand Rock r _
5a.Well Location: m ft. 425 Blue Granite
Fred Lowe ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. n '' J
615 Boyd Dickens Rd ft. ft i :,a
Physical Address,City,and Zip ft. ft.
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 // 1 6/22/22
6.Is(are)the well(s)OPermanent or OTemporary Signature ofCdftified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: inYes or X)No with 15A NCAC 02C.0100 or ISA 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 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-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 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(trample-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 65 (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 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(glum) 15 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
Chlorine eoz completion of well construction to the coup health department of the county
13b.Disinfection type: Amount: P i county P
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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