GW1-2021-01547_Well Construction - GW1_20210309

a.'
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Barley 54.WATER`"WS
FROM TO DESCRIPTION
Well Contractor Name 300' r301f4 1✓ 11
3271-A 2021 lP ft. H fL lG vr� rye
NC Well Contractor Certification Number ��t�AR
15.OUTER CASING forhraltitirsed wel)s UR;LINER ifti" 6cabk
B & K Well Drilling Inc a►�n processing Unit FROM TO DIAMETER THICKNESS MATERIAL
p ft. Zol ft. 6 1/4 10 SDR-21 JPVC
Company Name /nJ,r/�/�l1b.I1VNER. G:ORTUSiNG 'eottiermaletnsedloo
2.Well Construction Permit#:�/ N'/ / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well caushut•timi permits(i.e.UI ,CmtnN,State.Vnrinnre,etc.)
ft. ft. in.
L ft. in.
3.Well Use(check well use):
_'1.7SCREEN"w
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Munici al/Public ft, t't. in.
❑Geothermal(Heating/Cooling Supply) Sidenti.I Water Supply(single) ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1lf GROUT:
OIrrigation O Wells>100,000 GPD FROM I TO MATERIAL" EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: JOM
20 ft, Bentonite Pour
❑Monitoring ❑Recovery rt.
injection Well:❑Aquifer Recharge ❑Groundwater Remcdiation
RA t E PA -if a licible❑Aquifer Storage and Recovery ❑Salinity Barrier TU MATFRIAI. F.MPLACF.MF.NT MF.THJD❑Aquifer Test ❑Stormwater Drainage❑Experimental Technology ❑Subsidence Control ft.-❑Geothermal(Closed Loop) ❑Tracer NGLOG attictcattataenalsbeetsifnecess.TO' - DE.SCR ON(color hardness,soil rock e, rain size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fE id fL
j�
4.Date Well(s)Completed: Well iD#
f4 /�,/ ft ���1✓ �•
Sa.Well ocation: W ��� i v
J �t /� ��`fl� ft ft.
Fact] Name p Facility ID#(if applicable)
ft. ft.Ph sisal A dress, uty,and Zip _
� o,1�� Zl..REAfA7tO
County rr/ Paarrccl`ifdentification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) ;2�2. ertif catioNW ture o ertified ell Con ct6.Is(are)thewell(s): ermanent or ❑Temporary
ygning this form.I herehv ce i that the icell(.r)was(were)constructed in acrtirdmtre with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
!f this is a repair,fill out known well construction information mud explain the nature oj'the of this record has been proi,ided 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
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 ire/ls list all depths ifdierent(example-3(a3200'and 2@!00')
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
ljwater 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) 3A Method of test:
C lox. Ta b s
13b.Disinfection type: Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018