GW1-2021-02272_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
Joseph Bailey T'- = a4.=wi1TER=Z(?1VlES.
.t
2d2� FROM TO DESCRIPTION
Well Contractor Name
/
3271-A 4�AA� ft ft D 4
iKt.t�Ilit ft rL
NC Well Contractor Certification Number Pro"; 3� �' .. ,lb UUTER:Gs1,SiUriG•#or me "-cased,sve s
Into' -& �sed"OV, FROM TO DIAMETER THICKNESS MATERIAL
B & K Well Drilling Inc
ft Qt ft g 1/4 'in- SDR-21 1PVC
Company Name �� J /, j /ti{/YAa/7/J/1/./1
16.: CASIIiT.G 012,T-t7i9TNG' eatlicrmal e3as!�-too 7:: ,:_
2.Well Construction Permit#- FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UiC.Cnunty,Stare,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
17'"SCREEN
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural OMun /Public ft rL in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑Industrial/Cornmercial ❑Residential Water Supply(shared)
n14 ROT!
❑Irri ation ❑Wells>100,000 GPD FROM TO -u MATERIAL EMPLACEMENT METHOD&A MOUNT-
Non-Water Supply Well: 0 ft 20 ft Be ntonite POUT
❑Monitoring ❑Recovery ft ft
injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
lg..$RrVIT! 4''R L'PACK:afp bYe i a
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO PiATFRtAi, EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft fL
.._
E3Geothermal(Closed Loop) ❑Tracer ,, 1�DRILLINGIE)6 attar8%addfhohalite ;;� <�-::
r
C7Gcothcnnal(Hcatin�CoolingRetum,+)� ❑Other(explain FROM TO DESCRtP N(colahardness,saittro6k e, in si etc.
under t#21 Remarks) ft /r ft Red-5'"a
4.Date Well(s)Completed: 7 V Well ID# I� f / ft ft r I
5a.Well Location: fL ft
P4//&air c ft ft f /��//1 •
Facility/Owner
ame fit!- lilt Facility ID#(if applicable)
ft ft
14M'1 /Vnr�P1F/-•jt�Aq O.r�"����/�II7 A16.' AL'�/I 1 ft
Physical ddress,City,an hip I fL ft
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
{if well field,one ladlong is sufficient) VICe 'fication:
N W �
6.is(are)theweil(s): tent or ❑Temporary aitu fCenr ell tractor Dlyg$r signia:g this farm.!here eat that the xvl/(,r)uvs(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �i N& i5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and!hat a cony
If this is a repair,fill out knomi well construction Information and explain the nature of the of this record has been provided to the xr11 owner.
repair under=21 remarks section or on the hack of this form
23.Site diagram or additional well details:
8.For Geoprobell}PT 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 iftiecessary.
drilled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft. s completion er the follow�n
For multiple n ells list all depths if different(example-3@200'and 2G7a Submit this GW-1 within 30 da 'of well letton 100'} ) y p p t
10.Static water level below top of casing:40 (ft.} 24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level is above casing,4se'•_if Ptocessi,ig Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter- 6 1/18 (in.) 24b.For injection Wells:Copy toy DWR,Underground injection Cornrol(rUC)
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,ro[ary,cable,direct nusfn,etc.) county environmental health departrhent of the county where installed
FOR WATER SUPPLE'V4•ELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCUA
13a.Yield(gpm) if
Method of test:Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
C or. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Rcvis-d 6-6.2019
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