GW1-2021-01540_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW`-1) For internal Use Only:
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1.Well Contractor information:
Joseph Bailey l4.WAT)RZONES
((��U FROM TO DESCRIPTION'
Well Contractor Name t.41 H� (�
7 ft 7° ft.
3271-A „ ten processing
NC Well Contractor Certification Number Dw Ir�torin�t`A' etion
R S� 15.OU IER CASING for molliased`tvells OR i INER tf,a "lieabte
B & K Well Drilling Inc FRDM TO DIAMETER THICKNESS MATERIAL
0 ft. firft. 61/4 SDR-21 JPVC
Company Name f f{J 1b•-IN)ER-CA'SING.OR.TUBING eothermil cliiita loo
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2.Well Construction Permit#: FROM ft. TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cnunn�,State.Variance,elc.)
fL m.
' ft. ft. in•
3.Well Use(check well use): / _
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in•
❑Geothermal(Heating/Cooling Supply) srdential Water Supply(single) rn ft. ft• in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 18 GItOi37
❑irri anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD& MOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pour
❑Monitoring ❑Recovery ft. ft.
injection Well: fa ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation 19.SAND/GRAYEti PACK df a lic3ble❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TU MATERIAL EMPI.ACEMF.NT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothenmal(Closed Loop) ❑Tracer 20:DRILLING LOG attsi( addld:' Ereetsif liecess
FROM TO DESCRiP N(color,hardness,sod/rock type,grain 'a,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft ft
ti.
4.Date Well(s)Completed: 0Z 211Well iD# /d7- - tt Q fL / ro✓d�? SO/
Sa.Well Location: '
O ft
v ft. ft. l~/lh� ems/ •/ �/`
Facility/owinerNamc Facility iD#(if applicable) fL V t
ft
Physical A dress,City,and Zip
C L" t �����3 21i�tEMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one tat/long is sufficient) 22.Certification:
N W
Sig tore of ertifi ell Cor9AC
Date
6.ls(are),the well(s): manent or ❑Temporary
signing this.(nnn./herehr ct the well(-s)was(were)con-stnicted in accow.lance with
7.Is this a repair to an existing well: ❑Yes or �N�1� 15A NCAC 02C.01!!0 or ISA C.0200 Well Construction Standards ana-.iat a cony
IJ'this is a repair.fill out known well construction information anexplain the nature of the of this record has been provided to the well owner.
repair under;21 remarks section or on the hack 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 construction info
construction,only l GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
For nndtiple hells list all depths if different(example-fg200'and 2(a3100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
7(waler level is above casing,use"+"
6'1/18 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) M ethod of test:
lor. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality•Division of Water Resources Revised 6-6-20I R