GW1-2021-02273_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I!"
Joseph Bailey S�j � 77, 7
4.,WATERZONES .
FROM TO DESCRIPTION � �
Well Contractor Name 021 I.
32 71-A ft. ft. ®<
NC Well Contractor Certification Number l':j�111)t 1g,OU IEIt f atSiNG.'for multi cased:tdells QR L i1VER if;a`"livable .>'.
FROM TO DIAMETER THICKNESS MATERIAL
B & K Well Drilling Inc ft.
0 J/ Ift. 61/4 i" SDR-21 JPVC
Company Name l I 1{:I]tPTER�GASiIVG;OR.TIJSING 'edftiermal elosd-loo
2.Well Construction Permit#: �� 40 L 1 FROM TO DIAMETER THICK\ESS MATERIAL
- List a!1 applicable well construction permits(i.e.U/C.Cmmty,State.T/nrinnce,etc.)
ft. fL in
ft. ft. in.
3.Well Use(check well use):
'1.7.SCREI:-1�' . - - _
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL 1t. in.
❑Geothermal(Heating/Cooling Supply) r ential Water Supply(single) t. ft. I in.
❑Industrial/Commercial ❑Residential Water Supply(shared) =-
❑Irrl BIIOn ❑Wells>100,000 GPD N20
MATERIAL4 EMPLACEMENT METHOD&AMOUNT
{
Non-Water Supply Well: 1e Bentonife Pour
❑Monitoring ❑Recovery ft.
Injection Well: rt❑Aquifer Recharge ❑Groundwater Rcmcdiation - L"PACK its' 'cable. .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F.MPI,ACFMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fl• 1L
❑Experimental Technology ❑Subsidence Control j�/ ft. ft
❑Geothermal(Closed Loop) ❑Tracer 2/oY�-DWLLINGLOG attac7 addiaorialsheetsitf
FROM TO DE.SCRR'TION(color.hardness soil/rock
type, ram stze,etc.)
❑Gcothcnnal(Heating/CoolingUReturn) ❑Other(explain under#21/Remarks) ft. ft a 4.Date Well(s)Completed: / Well ID# �411 /r C
fL ft gel UL r Cfr J d!
5a.Well Location y r/� / ✓ /�
/ , �JtI oA�}� �1.r��/�WQlJ f L �V�f G ":'� .•��• �� � (`+G
Facility/OwncrNamc FacilitylD# tfapplicablc) fL 0 ft. � Q•�
A u! _f7 4/ Adds S%a/7J 70� r l C, /IL ft ft
ft. ft.
Physical AcWrcss,City,and Zip
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Cer CatiO
N W
Si ature of ertified e I Contractor Date
6.Is(are)the well(s): manent or ❑Temporary
y signing this farm,/hereby certify that the,cell ft)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or SA NCAC 02C.0100 or 6A NCAC 02C.0200 Well Construction Standards and that a tort•
/fthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under'.,21 remarks section or on the back of this form. 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 pagelto 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-1 within 30 days of well completion per the following:^
For multiple wells list all depths ifdi,(jerent(example-3 00'and 2@I00) -
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
//'water level is above casing,use'•
6 1/18 24b.For Injection Wells:Copy to' W DR,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 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
Air Lift Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 41'a Method of test: I
13b.Disinfection type: Ch or. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources) Revised(,6-201 R