GW1-2021-00492_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wen Contractor Information:
Joseph Bailey I M WATPBZONES
mom TO DESCRIPTION
Well Coaracmr Name +-T fL 'Z�y it GJ1yJic" 17— Q]re
3271-A 7076 R o! Sr /' ' aC i c zd
NC Well Contractor Certification Number :FROM FRCTSnPCr - 'tFR ICKR d
B & K Well Drilling Inc FROM TO DIAMETER DR-2Eaa MATERLaL
9 0 H, R 61/4 1°• SDR-21 PVC
Company Name / .y J4 0 - OM iv OA -
l) ; FROM TO mAMEfER TnICRVF55 MATERIAL
2.Well Construction Permit R: (L (L tR
Lrn all applirnble well omrsnvrriml pennlrs A I IC.Crearv.Spate.sananre,en:)
fc R ha
3.Well Use(cheek well use):
'St7tE6Nr ... -
Water 5nppty Well: FROM To DUMETER •stAn Si2E TRICKNFSa aur_RIAL
OAgricultural 0munpixidlTublic fL R. in.
CGeothermal(Heating/Cooling Supply) ,dermal Water Supply(single) fL fb iR
a lsidusuiaUColtmercial OResidcomd Water Supply(shared)
Olrri lion ❑Wells>100,000GPD FROM TO MATERIAL • 6MMCEMEINT METHOD a AMOUNT
Non-Water Supply Well: O R- 20 m Bentonite Pour
OMautoring DRecovery n. R
Injection Well: 4 R
DAquifer Recharge OGroundwater Ranediation 0..SAND/GRAVEL PACK if.
DAquifer Storage and Recovery OSalinity Barrier FROM To MATERIA EmPt.ncrMEnT nuTxon
DAqife ur Test 05totmwater Drainage R R r
DExperimental Technology OSubsidence Control 2 rt
DGeOthermal(Closed Loop) OTracer
FROM TO DI ardves4 swVrrek in Ine,«e)
0Gcothamal(Hestin R ) 00thaexpinin ands#21 Remarks) R A.
4.Date Wells)Comp 1Wel1 IDM � V ft. f4ki ?/ Y'c
5s.Well Location:
(YI�I Q OML ft. R
fwiliry/Owner Name Fatiliry Inp(if licabk)
)MIJ4III4,got,
Physical A dres Ciry,and Zip _
el O !6✓ F III /; I� 'B,fFaMAR1C5
aunty
panel Idcmifierawn No.(PIN) Pad,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong Is sufficinx) 22 Certifi 'on:
N W 0 for /� UI
Si of en dl Cal /Gr Date
6.Is(are)Ihe well(s): nenl or OTemporary
•signurg rhq/orm.l hereby rernfy char tFe nell/.r)xnr(wen)rontnacred is arrar'mlre with
7.Is this a repair to an existing well: OYes or —Ipw_°✓ 15A MCAC 0IC.01M)or/SA NCAC0IC_0100 Well Coemictimr Smndards turd:iar a copy
fill oar kanvn veil rons"crion in mion ad explain the nature jthe of Mrs record hog been Prorldsd to the veil..er.
!,phis aa repair,Ji 1 m
rcpnir,uMer-71 remarkr tmimt or on the hack nJrhir Jnrm 23.Site diagram Or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well constmcton info
construction,only I GW-I is needed. indicate TOTAL NUMBER ofwclls (adI Over in Remarks Box).YOU may also attach additional pages if necessary.
drilled: f MITTAL INSTRUCTIONS
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9.Total well depth below land surfs . ) Submit this GW-1 within 30 days of well completion per the followiae
m Far ultip ce le lls f,all dryths ifdid eM(.ample-3®SOo'aM 2(1 ,
10.Stotle water level below top of Lasing:40 V:.. 24a•.For All Wells: Original form to Division of Water Resources (DWR),
aL}. information Processing Uniy 1617 MSC,Raleigh,NC 2 7699-1 61 7
lJ�wter hve(is above rnsing,use"+•'
6'�/�8 24b.For lajeetWells:n We :Copy to DWR,Underground Injection Cents*](TUC)
11.Borehole diameter: (in.) program,1636 MSC,Raleigh.NC 27699-1636
12.Well construction m Air Rotaryethod: Zde For Wa[er SDpDh and Open-Loop Geotitermal Return Wells:Copy to the
1 is auger,mtary,cable direct push,esc.) County environments:haith department of the :04111 where roan.
FOR WATER SUPPLY WELLS ONLY: 20d.Fo Wat< Wells producing over IOOA00 GPD:Copy to DWR,CCPCUA
13a.Yield(gum) - Method of tut:
Air Lift Pe tort P og am,16I 1 MSC,Ralegh,NC 27699 161 I
13b.Disinfection type: lop. Tabs Amount: 1 1/2 Lbs
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Form
North CHolina IXpamaent of EneimnmcnW Quality-nivuion of Watcr Rcaaaeys Revircd 6-6-201 e