GW1-2021-01084_Well Construction - GW1_20210210

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 1a WATERZOBES'
FROM TO DPSCRIPPON'
Well Comracror Name / fL
3271-A ft
NC W<Il ComnaorCMifcarion Number 15..t71DTEIE' o�ItisyaedweEa DR Lim
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 a �0 it 61/4 in. SDR-21 PVC
Company Name ^C J (� 16.INVER CASiCiG OR 7BBD4G ®a1
2.Well Construction Permit#: )O�/ 9� FROM TO DIAMETER THICKNESS MATERIAL
L:v all applirahle well rnrznrv<omi permua ti.e. 2C.Counrv.Stme.Vnrianra.eta J tt ft. in.
R t n-
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) rdtntid Water Supply(single) ft fL fir.
01nduvtrial/Commercial OResidential Water Supply(shared) IR GROUT
,.: _
❑Irrlation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETXODa AMOUNT
Non-Water Supply Well: 0 fL 20 a Bentonite Pour
OMonieonng ORmovery R ft
Injection Well: fr. tL
❑Aquifer Recharge ❑Groundwater Remcdiation 19. t.12AVEL PAGIE a hie
OAquifer Storage and Recovery ❑Salinity Balder FRUN TO MATERIAL F.MPLACi.MF.NT MFTHUD
OAquifer Test ❑Stommvater Drainage R it
❑Experimental Technology ❑Subsidence Control tt D.
.OGeothermial(Closed Loop) OTracer 7b..DRIE.LINGtiOG uhrL.additioal allusi V. 97)
FROM TO DESCRIPD N enkr.hardo swurak
CGcothennal(Hcating/Coolin Rcmm) Collier(explain under#21 Remarks) ft
4.Date Well(s)Completed:_� Well ID#_ ft. 41 R !GN/
5a.Well Location: JtMarld I� 8y1'/ RXrft
R It /
Facihry OsoCT Namc Faziliry IDi ofapplieable) ft91,
It. •h r✓
/12 &Ilai �d t
ft, H.
Physical Address,City.and Zip
Wy _0/_r/1,//,� 21.REMARKS
County A Patccl TTdcnn6fieaeonn No.
(PIN)
5b-Latitude and longitude in degrecti mmutes/secouds or decimal degrees:
lit well field.one lavmng is sufficient) 22.Certification:
N W
6.I3(2re)the well(s): ermanent or OTemporary
ign S rcofiC fin e actor DwIC
R emngthis/arm.I henh,r,ftfy:hat ne///rJ•'as/wercl ronsmrrteal in a-'..rdcuu e,wh
7.Is this a repair to an existing well: ❑Yes or lie NCAC 02C.0100 nr 15A NCAC 02C 0200 R'e/1 Cm snvcoa,,Standards arol that a copy
If this is a repair.fill act knavm.ell a onnnrcrinn ie/nrmarinu and explain the nature n/the J this record has Aeen pmridrd ra the well awno.
repair arxler-21 remarks secomi nr an the back a(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
consnuctim.Only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Over in Remarks Box).You may also attach additional pages ifneeessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
•9.Total well depth below land surface: r (ft.) ��}¢' ppthis GW-1 within 30 days o(well completion per the following:
Fur malriple yells lur all depths ifdp rem re mep/a-3(4)Im0'a•d 2j Mff) I C 1 S;dlUL
40 242. For All Wells: Original form to Division of Water Resources (DWR).
f 10.Static water level below lop of casing: (TO Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If warn level is above rasing.use
6 1/18 - 24b.For Injection Wells: Copy to DWR,Underground Injection Co:arol(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water So DDIv and op n-Lo D Geothermal Rcmm Wells:Copy to the
11.c.auger,mrary,cable.direct push.ae,) county environmental health department of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over'00,000 GP I'Copy to DWR,CCPCUA
132.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: tor. Tabs Amount 1 112 LbS
Form GW-1 Nonh Carolina ricpartmene of Environmental Quality-Division o.Weter Resource Revised 6-/-2019