GW1-2021-01603_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
7.7
Joseph Bailey 14rwAr>R.zorrEs,
FROM TO DESCRIPTION
WclI Contractor Name ft ' ft '/
3271-A ft. fa /
NC Well Contractor Certification Number 15:0 TER.CASIIlG.fSY'snu -tabedwdls OR:EiI?TER rf t `Iieabte
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. t- 6 1/4 ' ia• SDR-21 PVC
Company Name /O/ 16:l'NNER GA 1NG ORTUBING' 6tlieialm eloseddoo m;
2.Well Construction Permit#• �� (�+� FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.Counrv,State.Variance,etc.) ft. ft in•
ft ft in.
3.Well:Use(check well use): ko
17.SCREEN,_
Water Supply Well: FROM I TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Muntct al/Public ft R• in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft ft in.
❑Industrial/Contmercial ❑Residential Water Supply(shared) 18: ROUT
❑Irri ation ❑WelIS>100,000 GPD FROM I TO _^MATERIALS EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 1 20 ft Bentonite Pour
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL PACK'ifa ligtile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM 1 TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 44
ft. ft
❑Geothermal(Closed Loop) ❑Tracer 2fliDRILL7NGZOG atlac7iadditiaaalIteetsrfoeeeas
FROM TO DESCRH' UN(color,hardness soil/rockram nee,etc.)
❑Gcothcnnal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) It ! , ft 17eillfOf
4.Date Well(s)Completed:4%T Well ID# ft d ft
` /O�
Sa.Well Location: ft ft r 4
rl!rft- %
y H/
— ft. ft
acility TD#(ifapplicic) ftFac i&Owncr amc
5r � 1;�, k — yo � AX
ft t
ft ft
Physical Address,City,and Zip
I / � /G la,, 21REMARRS'. i
T
County �C Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certific lion: Ir.-,I1"�77^��` _ � C nritOil
t-) U R�+
N W
Signa eofC [ified ontractor Dat
6.Is(are)the well(s): rmanent or ❑Temporary
Bp igoing thisform,1 hereby certify that the ryel[(s)was(were)Constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Vq__ 15A MCA 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this it a repair,fill out known well construction information and explain the nature of the of this record has been provided to the%v11 owner.
repair under r.'21 remarks section or on the back of this form. 23.Site diagram or additional wellidetails•
You may use the back of this page Ito provide additional well construction info
8.For GeoprabelDPT or Closed-Loop Geothermal Wells having the same
(add'See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0� (it) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2L100')
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 water level is above casing,use"+" i
611/18 24b.For Injection Wells:Copy toIDWR,Underground Injection Control(TUC)
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
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13s.Yield(gpm) It d Lof Method of test:
lor. Tabs 1 1/2 Lbs
13b-Disinfection type: Amount:
pI
Form GW-I North Carolina Department of Environmental Quality-Division of"kater Resources P Revised 6-6-201 R