GW1-2021-00487_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only'.
1.Well Contractor Information:
Joseph Bailey IdWATERZONES ---
FROM TO DESCRIPTION
Wcn Contractor Namc rt. ��� rc
o
3271-A �' 4iiR :2'y�tdf�
NC Well Contractor Cerifirron Number CC RCASFNG for meld-casedwells OR LINER 0. Enble
B & K Well Drilling Inc FROM DI MFTER THICKNESS MATERIAL
0 ft. 5 7 fc I61/4 in. SDR-21 PVC
Company Name 16.INNER CASING OR 1 U6LNG eothermaI class
J _/�� IRON TO DIAMETER THICKNESS MATERIAL
2.Well Cons[rucdon Permit N: (A C"I"" rt. ft-
Lnm n/I apPlirahle well rn„a,union permirs fi e.Ul ,Carron.Scare-Fnrtmse.errs
3.Well Use(check well use): 1 SC
4 in R in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS NaTERIAL ~
❑Agricultural OMunicipabPublic AL fl. OL I
C Geothermal(HeatingiCooling Supply) ential Water Supply(single) It in.
❑Indusurial,Commercial ❑Rcrdential Water guppy(shared) I&GROUT
731ra ation ❑Wells> 100.000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 in 20 fc Bentonite Pour
❑Monnoring ❑Recovep' n. Or
Injection Well: H. fL
❑Aquifer Recharge CGroundwater Remediation 19 SANDIGRAYEL PACK If a eeafile
GAquifer SIOraaC and Re<o\'ery ❑Salnuty Barrier FROM' TU 11 TERIAL EMPLACEMENT METHOD
i . ,Aquifer Test CSlornmacer Drainage
❑Experimental Technology ❑Subsidence Control 11 ft. in
❑Geothermal(Closed Loop) ❑Tracer 20.DRD.LING LOG Utdch ral"Oeal shmctifoeceaary
mom TO DMCR no'(color.hardness.sar nick e, ra,n size,cry
❑Geothermal(H"OneCooling Rclum) OOthcr(explain under N21 Remarks) ft fa
a
J.Date Wells)Completed: "a/ Well IDSZ ft. ^�/fc
ft, ft.
Sa.W'ell LPPca�do rC� J o• 1
rL�IW4//8� CGS IaY.J ft
FaciliryrOwncr Nja/m< /�/q/ 1 Facilirtry,TD§(Ifapplicablc) ft fc
re r1. 1
P�hy/s�m�a�A� r.s,Ciry,and Zip
County Parcel Identification No Wrl
51j.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(it well field,once,long is suffciect) 22.Cer[ifica
N W �
Si a Cem ed cut cm Datc
6.Is(are)the well(s): manem or CTemporan
Bi. pnnip chin rm Ilmrehr rerr, hat the,.eU(slant/u'e.eJ cnnsvin redm a.rnrdanae muh
7.Is this a repair to an existing well: ❑Yes or C>-� li. NUC 02C 0101)cr li A NC C 02C.l1200 Rrell Cmrarvcrion SrandorQe and char a copr
/1 chic i.a repo,r.Ill our{onu well mnnn,nion,nfonnonmr and explain rde nature nl the /a,i,.record hrso Aeen rym,ded m d,c.elf owne.-
repmr andrr 'J remarlr racnn„err o„the nack j,vis/nr�, 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 coustrucuon info
construction,only I GW-I is needed. Tndicam TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary'drilled'. TJ�MITTAL INSTRUCTIONS
9.Total well depth below land surface: S t^') Submit this GW-I within 30 days of well completion per the following:
Fo. ... le Mery rrr au dewl��'Td of c,n feannrple-3Ca2nn and 2C4100)
24a. For All Wells: Original form to Division of Wa[cr Resources (DWR).
10.Static water level below top of casing:40 (ft) Information Processing Unit, 1617 MSC.Raleigh,NC 2 7699-161 7
If—,,r leveliaahove...sing.ute -"
6 1/18 24b. For In section Wells Copy to WAR,Underground Injection Control (TUC)
11.Borehole diameter. (in.) Program.1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary
24c.For Water S DDI d Open-Loop Geothermal Return Wells:Copy to the
1.a auger,rosary.calla r l pacts,.eta.) count,environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producirl over 100,I100 GPD: Copy to DWR,CCPCUA
132.Yield(gpm) r Method of test:
Air Lift Penmit Program,1611 MSC,Raleigh,Ni-27699-1611
or. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Form GW- Nonh Carolina Dcpartmcm of Envkonmcnul Quality Dlcivon."Werror Rcsour-ss Rc✓sad 6-6201A