GW1-2021-01548_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information: RECEIVED
Joseph Bailey ]a wAr�R°zoNPs
FROM ITOADIE!I[P)SCROWei I Contractor Name Vft3271-A Information Processing Unit �- oft. `Wellale;; d•J-C
NC Well Contractor Certification Number DWR Section ;7S.OUTERCASING idrtnult&c dd=wills OR11NEIL if i"Ticable c--i'
FROM TO DIAMETER THICKNESS MATERIAL
B & K Well Drilling Inc
p ft. ft- 61/4 in- SDR-21 PVC
Company Name /a1 0 � f
„ 4b'INNER CASING OR,!-U G eutheriniIA6sEd466
2.Well Construction Permit# o (/JI FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permit.[(i.e.UIC,Cotnrv,State,Variance,etc.)
t. ft in•
ft- ft. in.
3.Well Use(check well use):
.17i'SCREEN '
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munro al/Public ft tt. in.
❑Geothermal(Heating/Cooling Supply) esidenlial Water Supply(single) d/ it, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '499.GROUT +
❑ltri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pour
❑Monitoring ❑Recovery ft. ft.
Injection Well: rt, ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation
]9 SSANDlGR IVEI PACK if a licahli
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fG fL
❑Experimental Technology ❑Subsidence Control
DGeothennal(Closed Loop) ❑Tracer
addltloaal
20:DRTLLINGLOG attaibheetsifdecess K
FROM TO DESCRIP ON(color,hardness,soil/rock—a rain s1m etc.)
❑Geothermal(Hcating/Cooling Rctum) ❑Other(explain under#21 Rcmarks) I fL ft.
4.Date Well(s)Completed: Well ID# - ty 11 eft /
fL ft �r J-Il+✓/ �'� a(/l
Sa.Well Location: _
ft.
Facility/OwnerNamc / , ft
/Fayflliitty lyD/ f#(if a/pplicablc) ft. 6 - -4,2.
51
Physical A re city,and Zip
ell
4 101 2]:REMARKS.
ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:N W
Si tune of ertified ell Con ra r Date
6.Is(are)the well( ermanent or ❑Temporary
y signing this.form.1 herehv ee �that the uell(s)was(were)constructed in accordance frith
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 and explain the nature nj'the of this record has been provided to the+ill owner.
repair under a21 remarks section or on the back ofWt 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: tee/ 24.SUBMITTAL INSTRUCTION
AS
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9.Total well depth below land surface: (�y.-1 —(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-iP(3a 200'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
lfwater level is above casing,use•'+"
6.1/18 24b-For Injection_W_ells:Copy to DWR,Underground Injection Control(IUC)
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
13a.Yield(gpm) 20 ,0 Method of test:
Air Lift Permit Program,161 I MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Cor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 R