GW1-2021-05715_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey 4 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Namc
3271-A �UL 0 2021 Oft. ft. J (� Qjtt
NC Well Contractor Certification Number 1 p 15.OUTER C SING(for muld-cased wells OR LINER if applicable)
B & K Well Drilling Inc `'frJGf3§51(1� FNOM l0 UTAM E'ItER THICKNESS MATERI.aI-
3ti071 0 tf. tt. 61/4 , i^• SDR-21 PVC
Company Name J J
A19,3� �� � 16.INNER C-4SING OR TUBING eothermal closed-loo2.We11 Construction Permit#: JSCREEIN
r0 DIAMETER THICKNESS MATER[At.
1-ict n!!npplicnhle++'ell rnaruaavimr pc>rm;ts ti.r.GIC.C•nurn•.5tnte.I"arinnrr.err 1
ft. in.
in.
3.Well Use(check Nell use):Water Supply Well: TO DAMETEH SLOT SA.F. THICKNESS MATERIAL
OAgricultural OMunicipal'Public It. ft. in,
[]Geothermal(Hcating,Cooling Supply) stdential Water Supply(single) /!rt• rt.
GLidustrial'Commercial ❑Residential Water Supply(shared) I&GROUT
OItTi ation D ells> 100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD B ANIOUNT
Non-Water Supply Well: 0 ft. 20 rt' Bentonite Pour
[]Monitoring ORecovety ft. ft.
Injection Well: ft. ft.
OAquiferRechargc GGroundwaterRcnicdiation 19-SAND/GRAVEL PACK(if applicable)_
OAquifer Storage and Recovery OSalinity Ban-ier FROM TO MATF.RIAL F.MPI.ACF.MF.NT pIF.THOD
[]Aquifer Test OStormwater Drainage
❑Experimental Technology OSubsidence Control
❑Geothenmal(Closed Loop) ❑Tracer 20.DRILLING LOG fattach additional sheets if necessary)
FROM TO D&SCRIP ION(color,hardness,soil/rock type.Drain size,etc.)
[]Geothermal(ficating;Cooling Return) OOthcr(explain under#21 Rcmarks) ft.
4.Date Well(s)Completed: Well ID#1 fL L
rt. rt. OA/If S'Qi 1
5a.Well Location: AMD
ft. fL �1
��? Of XC4(s� S�� /
FaciliryiowncrNamc Nd_A �FFaaccii^litylnk(ifapnlicabic)
Phvsical Address.Citv,and Zip. ^/F /► /.�,
?IN)
21.REMARKpParcell Identification No.( V ( C *
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if udl field.one latilong is suitic lent) 22.Cer[i ication:
N Qa
Si azure of enific ;c I Cont fur. Dail
6.li;(are)the w•ell(s): [anent or Ol•emporar}'
r s{;nige du<(non.1 hrrehr et ih'that due irell(c)n'as Nvre)ennsovrted irr aec nrdauee+rith
7.Is this a repair to an existing well: ❑Yes or /i.�..\CaC n1C.nlon nr ISA ..4C 02C.o'Oo ff'ell Cmr,ctrurti),Standards cord that a cnpr
/f du.t is a repair.(I/nut knot n++'ell cnnsuvetintr in fnnnurinn and etplain the•rattu'c•nl7hr
of this record has been prnnded to the hell nHwer.
repour under 2/rcnnm•ks section or nn the hack n/dti.s/nun` 23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
Fur nndtiple u­l/s list all de.vths f/different tecnnple-3�i�n_n"nnd-1!4;10n'l
24a. For All Wells: Orilginal form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 (ft•) Information Processing Unit.1617 MSC.Raleigh,NC 27699-1617
IJl rutrr lrrrl is chore can-Gr�,wr..�.. 4 j h. For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program.1636 MSC.Raleigh,N627699-1636
12.Well construction method: Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.c.auger,rotanti.cable.direct push.etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water yy'ells producing over 1OQ000 GPD:Copy to DWR,CCPCUA
Method of test:
13a.Yield(-pm)
Air Lift Permit Program.1611 MSC.Raleigh,NC 27699-161 I
j13b.Disinfection tp ye: or. Tabs 1 1/2 Lbs Amount: I
Fonn GW-i North Carolina Depannicnt of En.ironmcnia!Quality-Di%i.uon at Water Resourc s Res iscd 6-6-2018
I