GW1-2021-02268_Well Construction - GW1_20210521

4 G_X -t-d� T
WELL CONSTRUCTION RECORD(GW-1) Por internal Use Only:
1.Well Contractor Information:
i
Joseph Bailey 14.WATER ZONES
FROM TO DESCRIP. ION
Well Contractor Name
L ft.
3271-A ft. ft.
i
NC Well Contractor Certification Number 15.OUTER CASING(for could-cased wells)OR LINER Etta licable
B & K Well Drilling Inc FROM Tode DIAMETER THICKNESS MATERIAL
0 ft. t. 61/4 1 in SDR-21 JPVC AV
Company Name p a y y 7�3 16.INNER CARING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: FROM 'to DIAMETER THICKNESS MATERIAL.
List all applicable++ell constru(iini,peanuts(i.e.L7C.Counrr.State, I ariame.err.) ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
] .SCREEN
Water Supply Well: FRONT TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici I./Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) slderrim Water Supply(single) t. ft. in
❑hldustrialiCommercial ❑Residential Water Supply(shared) i .GROUT
❑h7l atlon ❑Wei ls>100.000 GPD FROM I TO Nl.%TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite Pour
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO NUTERIAL EMPI.ACF.MF.NT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
AOU
❑Geothenal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach.additional:sheets if necessary) .:
FROM TO DESCRIP UN(color, rdness,snillrock � e,grain size,etc.)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Rcmarks) ft. 1,6 ft. Q
4.Date Well(s)Completed: 7 / Well ID# 1
ft, ft. O, • �.
Saa.�..Well Location:
ft.
ft. ft.
Facc^^i //
ilJlityOOwnn�ccr mr/Na ac/il�iy itt/IDDky�((if%ap�plicaabble)
Sd,• ry-�(�jlrl ��� �J / /r./�4A�►�J(///!�. ` ft. fL � ���'�
�� ft. ft.
Physical JA ,c,,,,Jity.and Zip
21.REMARKS Uzi
ountY Parcel identification No.(P1N t
Ge;jS,,Se. t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwdl field,one latllong is suilicicnt) 22.Certifi 'On•
N W a/
6.Is(are)the well(s): ermanent or ❑Temporary acure of rificd II ntractor Da
//� r si,�nln,£t hi,c Jnrur.1 hereto'rertifi� h die ve11LU u•as(++rrel rnhrcnucteAin arcnr<fanre critic
7.is this a repair to an existing well: ❑Yes or Weo OA.\'CAC 02C.0100 or 15A YCA C./1'(!0 li'el/Construction Standards and that a cnpr
4 this is a repair,fill out knnwn nrll constvction infornianon and explain the nalare of the of this record has been pan ided to the+iell ouwer
repair under..21 remarks.sertinrt or on the hack n/this/ornr.
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-i is needed. indicate TOTAL NUMBER of wells (add'See Ovei'in Remarks Box).You may also attach additional pages if necessaty.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
Far nu hiple,re11s list all depdrs i attl1 rent(ernnhple- .d_i]00 and 70100')
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,NC 27699-1617
If viler lrrrl is share casing,use"+"
6 1/18 24b. For Iniection Wells:Copy to DWR,Underground Injection Control(iUC)
11.Borehole diameter: (in-) Program. 1636 MSC,Raleigh.NC 27699-1636
Air Rotary
12.Well construction method: 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) e0hin Method of
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-161 1
test: � ';
13b.Disinfection type: Ior. Tabs ,amount: 1 1/2 LbS
Form GW-I North Carolina Dcpanment of Environmental Quality-Division of Waicr Resource's Reviscd 6-6-2018