GW1-2021-03469_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) I For in emal UseOnly:
1.Well Contractor Information: d'
Joseph Bailey 74.WATER ZONES I
FROM TO DESCRIPTION
Well Connector Namc ft. ft.
3271-A JUN X 7 2021
ft. ft.
i
NC Well Contractor Certification Number Unit 15.OUTER CASING for muld-cased wells OR'LINER if a licahle
B & K Well Drilling Inc Ie�forim--ion prJCeSSIng FROM UTAMETEN THICKNESS MATERIAL
ML .Alp Sedion0 ft. ft. 61/4 1n• SDR-21 PVC
Company Name �� 16.INNER C G OR TUBING eothermal closed-loop)
2.Well Construction Permit# FROM 10 UTAN1 E'1'EN THICKNESS MATERIAL
List all applicable well(rmstruction permits(i.e.L-%/C.Cron•.Sate,i�rinnre.etc.) ft. ft. in.
ft. ft. in.
3,Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER! SLOT SV.F. THICKNESS M.>TENIAL
❑Agricultural ❑Munict ublic ft. ft. in.1
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft. fL in.
❑industrial/Commercial ❑Residential Water Supply(shared) 1 .GROUT
❑Ir•i ahon ❑Wells>100.000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 ft- Bentonite Pour
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Rcincdiation 19,SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRONT TO hUTF.RIA1. EMPLACF.MEST METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
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❑Geothermal(Closed Loop) ❑Tracer 26.DRILLING LOG(attach addidonal.sheets if necessa
FRONT TO DESCRI TION(color,hardness,soilirock e, rain size,etc.)
❑Geothermal(HcatingiCooling Return) ❑Other(explain under#21 Ranarks) f3 ft
ll
4.Date Well(s)Completed: Well ID# D ft. ff. V- seY
ft. ft. ,r" ro� �-
5a.Well Location:
�,p
/LrhO� Ave vi'/C� ft. � ft. C
Facility/Owner Namc Facility I DDk`(i`f�applic✓able) f[, fL
`� / ft. f4
Ph si Addr s,Ci[,nd Zip
21.R MARKS
«�
County Parcel Identification
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.1-Ae-
ificat•Al
n: /
N W e t [
5 tore f Cer[ifie Contractor D
6.Is(are)the well(s): rmanent or ❑Temporary
r si,�»inns dais Jnn».!herehr reni fi tat the irell/.d was(were)rnnsirucied in accordance hide
y��^� 1 i.A.VCAC 02C.0100 nr 15.a YCAC 02C.0200 Well Cnnctr-urtinn Standards and that a co/n•
7.Is this a repair to an existing well: ❑Yes or
of this record has heen pmrided to the well n-wr
this is a repair.ill out known well construction information and explain the nature of the
If
repair under 11 remarks section or on the hack nj this Torun. 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See 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-I within 30 days of well completion per the following:
Far....duple irclls list all depths ifdif/erent(esnople-3!ga100'and 2(d).100')
40 24a. For All Wells: Original fohn to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) (,formation Processing Unit,1617 MSC.Raleigh,NC 27699-1617
1/lrater level'is above crosing.use"+- i
6 1/18 24b.For Injection Wells:Copy to 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[oon 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 producinglover 100,000 GPD:Copy to DWR,CCPCUA
Air Lift Permit Program.1611 MSC.Kaleigh,'NC 27699-161 1
13a.Yield(gpm) Method of test:
lor. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
. . Revised 6-6-201 S
Font CiW-I North Carolina Department of Em ironmcntal Quality-Dicisiat of NN'atcr Raourcca .