GW1-2021-01543_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Von
Joseph Bailey ®/M
ld.WATER�t�NE6 °, '
FROM TO DESCRIPTION'
Wcl I Contractor Name o ft ft � /,(•� fit;
3271-A �l1 Ak X 9 1 ft. ft
NC Well Contractor Certification Number U�`t 15:OUCERCASING for rtaYti'cased'tvell' OR LINER d a"[aab
B & K Well Drilling Inc In;��,On provess`n� F OM fL TO ft m DIAMETER THICKNESS MATERI.�L
` 61/4 SDR-21 PVC
Company Name ��y 1(/Gl 1(,alj!i�iER,C iSING OR TI113G, 'eux7ietmal claseda
2.Well Construction Permit#: : �t W<I �� T EOM TO DIAMETER THICKNESS MATERLL
List all applicable well consbvction permits(i.e.U1C,County,State.Variance,etc.)
fL ft m
/' ft ft in.
3.Well Use(check well use): ,•
f2'SCREEV'`
Water Supply Well: FROM TO DIAMETER SLOT SIZE,( THICKNESS MATERIAL
❑Agricultural OMunicipal c fL fa in.
❑Geothermal(Heating/Cooling Supply) rdentral Water Supply(single) L {t in.
Dlndustrial/Commercial ❑Residential Water Supply(shared) 18:,GItOUf
❑irn ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&A.MOUNT
Non-Water Supply Well: 0 ft 20 fL Bentonite POUT
OMonitoring ❑Recovery ft. fL
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation r
19.SAND/GRAVE PACK-ifa eptile
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL FMPI ACEMF.NT METHOD
q
❑A uifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20 BRILL3NGI UG atfaefiisddtCo5ttii sheeh?tf -t='
FROM TO DESC IPTION(color,hardness,soiUrock e, stz„ete.1
DGcothcnmal(Heating/Cooling Rctum) ❑Other(explain undcr#21 Remarks) {e ft
4.Date Well(S)Completed: J Well iD# 4 G ft. c-2 A ft f tom/
ft fL
5a.Well Location:
f� Cis/!/✓rl /J'� LI:.L/Y�. s'i" .A.lm ft ft
Facility/Owner Namc Facility iD#(if applicable
ft ft.
ft ft
Physical Address,City,and Zip
y ',/� /•�� 22':72EMA'RKS.: ' 'r.�
co
­rc`ounty Parcel identification No.(PIN) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certification: ,
N
W /
ature ef
o erti to ell Contracto Dat
6.1s(are)the well(s): ermanent or ❑Temporary
/ ,signing this form,l herebi:certi that the xell(.$)xas(were)constructed in accordance with
7-[s this a repair to an existing well DY¢S or gltt6 I5A NCAC o1C.0100 or ISA.N AC 02C.0100 Well Canstrvcrion Standards arsd,'ia!a coat
If this is a repair,fill out knoxat well construction information and explain the nature Of the
of this record has been provided rO the xell Owner.
repair under 21 remarks section or on the hack of this form 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construe+•on info
c For Geo or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
constructionn,,o onllyy I GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (2 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a3200'and 2(a3100')
242. For All WellF. Original form to Division of Water Resource,. �DWR),
10.Static water level below top of casing:40 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If tearer level is-above casing,µse"+'.
6 �/�8 24b.For injection Wells:Copy to DWR,Underground Injection Chrtrol(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supple and Open-Loop Geothermal Return Wells:C(•py 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 producint over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(•pm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NL.27699-1611
13b.Disinfection type: lor. Tabs Amount: 1 1/2 Lbs
Revised 6-6-201 R
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources