GW1-2021-03468_Well Construction - GW1_20210607

WELL CONSTRUCTiON RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3271-A rt. ft. lilw
NC Well Contractor Certification Number !-c _//
1 15.OUTER CASING for muJlti/c�as�e9d wells OR L_ if a licable
B & K Well Drilling Inc pro�eSSing Un FROM 70 + DIAMETER THICKNESS MATERIAL
.- V ��OvrO 0 ft. ft- 6 1/4 ' SDR-21 PVC
Company Name 2/ `A 16.INNER CASING OR TUBING etither a]closed-loop)
2.Well Construction Permit#- , )�LJ�O FRONI TO DIAMETER THICKNESS MATERIAL
Li.a all applicable well construction permit..(i.e.C�IC.Cnrum•.State. l arionce.etc.) ft• ft. in.
in.
3.Well Use(check well use): ft.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSI7.E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in•
❑Geothermal(Heatingi'Cooling Supply) sidential Water Supply(single) t. fL in.
❑Industrial"Contmercial ❑Residential Water Supply(shared) g•GROUT
❑Irrigation ❑We[is>100.000 GPD FROM TO AIATERI.AL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bentonite Pour
❑Monitoring ❑Recovery
injection Well: tt ft
❑Aquifcr Recharge ❑Groundwater Rcnicdiatiun
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To M.%TFRIAL F.MPI.ACEMF.N`T METHOD
❑Aquifcr Test ❑Stormw•ater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
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❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional.sheets if necessary)
❑Geothermal(Ficating/Cooling Return) ❑Other(explain under 421 RcrnTk FROM TO DESCRI TION Rolo,hardness.soil/rock typa gnin size,etc.)
ft. / ft. aT
4.Date Well(s)Completed: / Well ID# it-f t U fc. O,I SOS
Sa.Well Location: G ft. ft. -0 d
•
fI. ft.
Facilny%OwncrNamc Facility lnc(ifapplicable) ft. O ft e
ft. fL
Physical Ad r11ess, ' and Zip ft. ft.
� 21.REMARKS
County Parcel IdentificationNo.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one laUlong is sutlicient)
e 22.Cert•ication-
Sig N W Sit, fcd
6.is(are)the well(s): mannt or ❑Temporary ni /S!
ture ofW I Contractor Date
8r signing dtis%brit.I herehr c'ert +d r the imWT)%,ar(were)constructed in arcardaiwe With
7.is this a repair to an existing well: ❑Yes or l i.4 A'CAC 02C.0100 or 15.4 A'CA l2C.0200 If ell Consoacuion Standards u•.d.that a caln
l%dos is a repair.,jell act knotwi well coisiruction infarmation and explain the nature of the q/rha record has been provided to r ie hell awger.
repair uncle r 21 remarks sectiai or on the hack nl'rhis jorni.
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
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMiTT.AL INSTRUCTIONS
9.Total well depth below land surface:f!)�] (ft') Submit this GW-1 within 30 days of well completion per the following:
Fur nudtiplc n•clls list all depths irdilferew f,rw ple-3;&200'and 2(d1100')
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,1617 MSC.Raleigh,INC 2 7699-1 61 7
Il ocher level h'abo:c casing.use"+•'
6 1/18 24b-For Injection Wells:Copy!to DWR,Underground injection Control (TUC)11.Borehole diameter: (in.) Program. 1636 MSC-Raleigh.NC 27699-1636
12.Well construction method: Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push.etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Pennit Program.161 1 MSC.Raleigh,NC 27699-161 1
Tabs I
13b.Disinfection type: lor- Amount: 1 1/2 Lbs
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Form GW-I North Carolina Department of Environmental Quality-Division of\Vacer Rexourccs Reviscd 6-6-'-01R
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