GW1-2021-00491_Well Construction - GW1_20210210

WELL CONSTRUCTION RECORD (GW-1) For Inte tint Use Only
I.Well Contractor Information:
Joseph Bailey laic WATER ZONES
F—. r DESCRIPTION i
W'dl connaaor Namc ft fL
3271-A i40 ft. /91 L I livrr r am` °AC
NC Well Contractor Certification Number IS.OUTER CASING Lt.mold-rased wdb OR LINER(f
B & K Well Drilling Inc ROM THICKNESS MATERIAL
TO UTAMETER t
Q rt. of, 61/4 SDR-21 PVC
Company Name .--s/^ 16-INNER CASING OR TUBING hernial desedJ
5 f/YnJ FROM O DIAMETER HICKFE55 ! MATERIAL
2.Well Construction Permit#: (1�
Lin all aPP;i er'able '1 o"Ib-1"co Pmit.P.e GIC Ceuno-.Sense-knrmn,c.em I d ft fL sn A
ft. ft in-
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT 512E THICKNESS 101wTEH1AL
❑Agricultural 71Municipa6Public ft. ft. in,
❑Ge,othermal(Hearma Cooling Supply) rden[ial Water Supply lsingle) it f. IL n
•
❑lndusm,l1C0mme1cnd ❑Rcvdential Water Supply(shared) I&GROUT
❑lip ation ❑Wells> 100.000 GPD FROM 1111 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q fL l 20 fI Bentonite Pour
❑Monitoring ORecovery n.1lkd
It
t✓�
Injection Well: ft. O.
❑Aquifer Recharge CGroundwater Remedialion -
• I9 SANDLGRAVEL PACK rf ITh bl 1
❑Aquifer Storage and Recovery �Salruuy Banter FROM f TO MATERIAL. EMPI-AQNF.NT M1IrTHUO
OAquifer Test CS[on ter Drainage f. ft
❑Experimental Technology ❑Subsidence Control f. I ft.
❑Geotherenal(Closed Loop) ❑Tracer 20.DRILL[NG LfG( Inch additiomishe,ta Boeasrarv)
mom TO DFSCRI OK(clot,hardnm s n—k 9M loan au,tld
[]Geothermal(Heating,Cooling Return) ❑Other(explain under#21 Remarks) I ft a S 6]'
4.Date Well(s)Completed:L l e J`11 Well lw /-O/ f` �(/ ft �Ldi✓„ O•/ _
O a. 11 ft A, G4.1 G9 Of li
Sa.Well Location: ..�y'
QJ'/< /�q//OX 0 r l//l ft. 9 ft s/ap SQL f^/ ra•-fe. 1
Facllin:Owner Namc Facillp #(if applicable) R �fL �/ /t C b•/ �� T5/d�T�
/.� t / J D°
l?
C
Physical Ad res� iry,and Zip
/ice 511 21.REMARKS
County Parcel ecmlficahe No.TIN)
Sb.Latitude and longitude in degreeslmmutevseconds or decimal degreez: r 11/0
(it well field,one lav long is sutfircet) 22.Certification:
rote r1crtl� Well Con ctor Date —/
6.Is(are)[he well(s): rmanen[ or ❑Temporary
g I""A f Ilereb r/y.h [[hell I1() as(werel o .s red in au d a,rulr
Is this a repair to an existing well Oyes or 54AC4(7 2C 0100 r!i4kC4Cn2C.n`or1 Nv,Ce;anvcr of 5rcndards aMr rnmy�
ePair,fit!our knnxn vd[ion r rr in/onnmmn an e[Pfmn the r ante f the ( I e ern d r h Prm d d h wed o
repair ender 21 remorkr section or on the heck of ih,s bens. 23.Site diagram or additional well details:
8.For Geoprabe/DPT or Closed-Loop Geothermal Wells having die same Yo{{u may use the back of this page to provide additional well constrce:ion info
construction.mi I GW-1 is needed. Indicate TOTAL NUMBER of-yclll r)Qks-{d See Over'in Remarks Rex).You may also attach additional pages if necessary.
drilled: D 1 C -24I.SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface:1Q, (fe) Submit this GW-I within 30 days of well completion per the following:
Fro'multiple rlG list all depths rldpj ten((e<ample-3@200'and l(a_100)
24a. For All Wehs: Original form to Division of Water Resources TWR),
10.Static water level below top of casing: 40 (ft.) Information Processing Unit,1617 MSC Raleigh,NC 27699-1617
If„arrrle,rl:,aha,ren,ing a,e
6 1/18 236. For Injection Wells: Cop}'to D0.R, Underground Inj ecuon Control (TUC)
1 I.Borehole diameter, (in,) Program. 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary 24c.For'At So I and Op n W'
-Loop Geothermal Return, -opy to the
LG anger,rotary,cable,d;mct push.em.) county environmental health department of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells p reducing over 100000 GPD: Copy toDWR,CCPCUA
13a.Yield(gpm) - Me[had of test:
Air Lift Permit Program,1611 MSC Raleigh,NC 27699-1611
tor. Tabs 1 112 Lbs
13b.Disinfection type: Amount:
Form G W-I Nonh Carolina Department of Em ironmcnuI Quality-Dlciuon of Wamr Resoumcs Re¢cd 6-6-'_0I F