GW1-2021-01544_Well Construction - GW1_20210309

WELL CONSTRUCTiON RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 1� � 14:wArER-ziv>rs v_,
FROM TO DESCRIPTION
WclI Contractor Name 2021
3271-A n ,�� •L �f` '�� ft. o� er�` Y �
`t�N ft. ft.
NC Well Contractor Certification Number vlti
95.0U,TER CASING `ot malt-cased well" OR;IINER d:a "Hcsb � -`
B & K Well Drilling Inc „ I(;�:t0� FROM TO DIAMETER THICKNESS MATERIAL
)n.,[ � 2 Sed0l 0 ft. ka I it- 6 1/4 in- SDR-21 PVC
Company Name
1L INtER C' OR.TIJBING eutlermal closed ioo
2.Well Construction Permit#:
FROM TO DIAMETER THICKNESS MATERIAL
��_� � ft ft in
List all applicable well construction permits(i.e.UIC,Cmtn(v.Stare.Variance,etc.)
ft. I ft in
3.Well Use(check well use):
17:SCREEN
Water Supply.Well: FROM. I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici ublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CRIC.dentiall Water Supply(single) ft ft• in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) qVi R40U
❑Ir•ri ation ❑Wells>100.000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20 ft. Bentonite Pour
❑Monitoring ❑Recovery ft. ft
injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAIvI)/GRA 1?EI P{CTC'•if a cable ro
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL FMPI ACF.MFNT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft rt
20sDRILL�1Cr L
❑Geothermal(Closed Loop) ❑Tracer OG/attadtaddthuaa131ieets1f
FROM 11 TO DESCR TION(color,hardness,sorVroek type.emin size,etc.)
❑Geothermal(Heating/Cooling Rctumm) OOther(explain Under#21 Remarks) ft ft J .
4.Date Well(s)Completed: f/ �1 Well ID# /A i ft- ft.
O ft. ft �17J i
Sa.Well Location: —
• ft Q ft
Facility ID#(ifa licablc a ft. ft
Facility/OwncrNamc Y PP )
ft ft
Physical Address,City,and Zip _
County s Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi ation:
i
N W
e of eni ed a Contra r Da[e
6.Is(are)the well(s): rmanent or ❑Temporary
„r Bp signing this fnrrn.1 herehr er fy that the we)1(,t)was(were)rnnstntcled in accordance uith
7.Is this a repair to an existing well: ❑Yes or �w�ru 15A AICAC 02C.0100 or 15A CAC OlC.0200 Well Construction Standards and that a copy
Ijthis is a repair,fill out knnxm well ronsrntctiar injormarion and explain the nature of the
njthis record has been provided to the xell omier.
repair under+;21 remarks section or on the hack njthis 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
(add'See Over iit Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: , 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 multiple hells list all depths ijdierent(example-3@200'and 2@100')
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
Ill vater 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 Suppy 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
13a.Yield(gpm) �� Method of test:Air Llft
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: or. Tabs Amount: 1 1/2 Lbs
Revised 6-6-201 A
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources