GW1-2021-05720_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I,Well Contractor Information:
Joseph Bailey 14.WATER ZONES
FROM TO I DESCRIPTIO.. -w
W.,11 Contractor Name
3271-A
i
NC:Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a licable
B & K Well Drilling Inc FROM i() U1.4MTHICKNESS l'MR1.M.
0 ft, ft. 161/4 in- SDR-21 JPVC
Company Name n� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit fy' FRUM I'U DIAMETER THICKNESS M. ERIAl-
1_ia nn npplicnh/e nx•11 cmtslrurrinn perntir.c li.e.C�IC.Cnunn•.State.I'ananre,el, I e in. C
3.Well Use(check well use): ft• i
ft to
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUT THICKNESS MATERIAL
❑Agricultural OM um VPublic ft. ft. in.
OGcothetmal(Heating/Cooling Supply) esidcntial Water Supply(single) ft• f. in.
❑h)dusuialicommercial OResidcntial Water Supply(.hared) 18.GROUT
❑hTi anon ❑\\ells> 100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite POUT
Otvtonitoring ❑Recovery ft. ft.
Injection Well: tt. ft.
❑Aquifer Recharge ❑(iroundwater Remcdiation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Bander FROM9,11-
TO M.%TF.RIAI. EMPI.ACFMEN'TMF7IIUD
❑Aquifer Test OStom)water Drainage ft.
0 -41
OF.xperimental Technology ❑Subsidence Control ft, ft.
OGeothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION(color,hardness,Wilrock e, rain size,etc.)
OGcothennal(FlcatingiCooling Return) OOthcr(explain underl:21 Remarks) ft. ft,
4.Date Well(s)Completed: Well ID#t ft. L n G<
ft. ft.
Sa.Well Location:
�sAS/fit yIGG �i/L
Faediry%OwnerNamc
Facility Mii(it'applicable) ft. ft.
ft�^ . ft.
for��y A -. ^yr �-
ft. Ct.
Physical Add css,City.and Zip -
�� 21.REMARKS
County Parcel Identification No.(PIN) /
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lif+s'tll field,one Iatilong is sutficicnU 22.Certifl ation•
N a a/
cure of 1 i i ont ctor Date
6.1'(are)the well(s): ent or OTemporary
si,;eine dti.c)non.I herehr rertifil !the ux 1/Cr)+rac(Nc eel emcetruered bt arrnnim+ce+rich
7.Is this a repair to an existing well: es or MNo /i.4 VC AC 02C.0108 nr l5.4 YC.4C 02C.tCnn the//Cmisnvetinn Standards and that a cnpr
r, Q� t i record has been prm-icled to the+vell nimi r.
l/dtis i.c a repair.ill inn knnx•n+rel(rrnectructinn infnnnmina and e.> a
eel under..21 rzr ar-kc seclinn ar an the back nJ this Jnrm. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havin,I)e ^, Jou may use the back of this page to provide additional well construction info
construction.only I G\\` 1 Cs needed. h)dicatc TOTAL NUMBEI} we V0 [ fS dd'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: j,{,MAILIITTAL INSTRUCTIONS
rmat/on Pro^esSA
�f
9.Total well depth below land surface: J e�
r��t
For nudliplu n'rlfs list n!/rfepdrs i%di%%rent(csrunple-3 a:.10n'and](d,/nn')
LJV"> 18610nSubmit this G\!'-1 within 30 days of well completion per the following:
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.16171 MSC,Raleigh,NC 27699-1617
!/lro/co lure/is ahore eating.list,"+"
6 1/18 24h. For Injection Wells:Copy to DWR,Underground Injection Control (1L'C)
11.Borehole diameter: (in.) Program. 1636 MSC.Raleigh.NC 27699-1636
Air Rotary
12.Well construction method: 24c.For Water Supply and Open-hoop 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
�{J� G Air Lift Permit Programm,161 I MSC.Raleigh;NC 27699-161 I
13a.Yield(-pm)_ 1.1-.7x Method of test:
Chior- Tabs 1 1/2 Lbs
13b.Disinfection type: Amount: I;
f
Form GW-I North Carolina Department of Environmental Quality-fhciston of'Watcr Resource I s Re\ised 6-6-2