GW1-2021-06657_Well Construction - GW1_20210706

x r'V 6 '3 02 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER
FRO)t TO DESCRIP7IUN
Well Contractor Namc {
3271-A r fr.
2021
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells OR LINER if a licable
B & K Well Drilling Inc t10�1 PfQl;e+z51119�1�11' FRONT TO t ft DIAMETER In THICKNESS MATERIAL.
0 ft• J 61/4 SDR-21 PVC
Company Name 1 1 �Lns 1 16.INNER CASING OR TUBING eothermal closed-loo
2-Well Construction Permit# J I L/3 f FROM .1.0 DIAME'reR THICK�k:Ss M.aTEat.>t.
Li.ct all applirahie yell rn,tcnvt<virot permir.c(i.e.L�/C.Cnannt State.I itriatre.en') ft. ft- in.
3,Well Use(check well use): /� tr. fL in.
17.SCREEN
Water Supply Well: FRONT I TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agriculturrl ❑Muntci Public ft, ft. in.
❑Geothermal(Heating+`Cooling Supply) sidential Water Supply(single) in-
❑Industrii&Coninercial ❑Residential Water Supply(shared) 18.GROUT
❑iri ation ❑Wells> IK000 GPD FROM TO Nt.%TERIAL EIIPLACEVENTh1ETHOD&A>IOUNT
Non-Water Supply Well: 0 fr. 20 ft.
Bentonite Pour
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharec ❑Groundwater Rerncdiation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FRV?t TO p %TF.RIAI. F.MPLACENIFN'T nIFTHUD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control fr. tL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if nemsa
FROM TU DESCRIP U�Icnlnr,hardness.soil/rock h e.drain size,etc.)
❑Geothermal(FleatingiCooling Retur) ❑Other(explain under 421 Remarks) h. fr.
{ 9
4.Date Well(s)Completed: 3 I Well IDtI Li� ' _ tt. tt.
fr. ft. p
Sa.Well Location: / r '
.�ft. ft.
_5rn
i 111 (�c_l rs
Faciliry,OwncrNamc Facility IDE(ifapplicable) ft. fL
. : fr. iL
jPhysical Adress.Ciit/ty.��and Zip ft. ft.
�__ J / LJ � •�S If Nli�l 21.REh1ARKS
County Parcel Idenritica@on No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
iif,cell field,one lat lone is srdlicicm) 22.Certification:
N W' a
6.Is(are)the well(s): rmanent or ❑Temporary Si amre of :erti icd well Conv for a[
�✓/ Br sienine dii.c form.l herehr rertih'brat the tt c 1lCU t+'ac(N en•1 rnnsu'urted in ar<'nrdanre n'irh
7.Is this a repair to an existing well: ❑Yes or �!eo 13.4 %'C.aC(11C.1)100 or li.i A'C.-IC o2C.(1'r11)11 ell Crulcrrmtrria»Srmtdardc turd ghat a cnpr
//this is a repair.Jill tart bme'n x'ell m»smurtinn it!fnr»mtiwt and explain the nano e of the
nil 7lu.c record hac peen prmided re)the,cell ntcucr.
repro under-:21 remarkc serrrino nr on the hack q/thic form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction inf-o
constn)ction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You nmay also attach additional pages if necessary.
drilled: y 24,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this G'•' A within 30 days ol'well completion per the following:
Far nudriplc+rclls list all depths fi dt(lerent teve tple-3:d,200'and-'•'d,100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below'top of casing: (ft•) Information Processing Unit.1617�MSC.Raleigh,NC 27699-1617
nwler level is'ahure casing,use"'.. I
6 1/18 24h. For Injection Wells:Cops,too DWR. Underground Injection Control (IUC)
11.Borehole diameter: (In) Program. 1636 MSC.Raleigh.NC'27699-1636
12.Well construction method: Air Rotary
24c.For Water Supply and Opcn-l.irop Geothermal Return Wells:Copy'to the
I 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 producin2`oJer 100,000 GPD: Copy to DWR,CCPCUA
Air Lift Permit Program,1611 MSC.Raleigh;NC 27699-161 1
13a.Yield(gpm) ethod of test: i
. bs
13b.Disinfection type: Ch or Ta Amount: 1 1/2 Lbs �
Form GW-1 North Carolina Department of En,'ironnrenial Quality-Division of Water Resources Rc,'ised 6-6-2019