GW1-2021-02275_Well Construction - GW1_20210521

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES I
FRO)1 TO DESCRIP ION
Well Contractor Name
3271-A G
fL ft.
NC Well Contractor Certification Number 15.OUTER CASING for could-cased wells OR LINER if a licable
B & K Well Drilling Inc FROM I'0 M DIAETER THICKNESS M.ATERI.AL
0 ft. t. 61/4 in. SDR-21 PVC
Company Name /fin /r y ay/y_ 16.INNER C NG OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• ///L//I�/ /�l/ 16V FROM '1.0 DIAMETER THICKNESS MATERIAL
Li.ct all applicable+cell rnnstruc Linn permicc(i.e.UIC.Cnmrmt Slate.f orianc e,erc.l ft. ft. an.
ft. ft.
3.Well Use(check well use):
( .SCREEN
Water Supply Well: FROM _ TO DIAMETER SLOT$p.F. THICKNESS MATERIAL
❑Agricultural ❑Munrci (!Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) t. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) i ,GROUT
❑ItTI ation ❑Weil->100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- 20 ft- Benton ite Pour
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Renncdiation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO M.XTF.RIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
OF-xperimental Technology ❑Subsidence ControlAEZ
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach,additional sheets if necessary)
FROM TO DESCRIP ON tcolor, rdness,sofl/m& e, rain size,etc.)
❑Gcothcnnal(Flcating%Coolin�g/Return) ❑Other(explain under#21nR'emarks) H. ft. Q
16
4.Date Well(s)Completed: 7 I Well ID# T v ft' tL
ft. ft. •
Sa.Well Location:
fr. fL
fL
Facility/Owner Name 'Facility ink(if applicable) T1. �.
ta
-� ft. e.
Physical A ress, ity,and Zip
2l.REMARKS
ounry Parcel identification No.(PiN r S,
Ir{Orl'i�:.tbn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1.0 r,�,: r
(if well field,one lat/long is sufficient) 22.Certifi ion:
N W Z
6.Is(are)the well(s): ermanent or ❑Temporary ;rature of rtificd , II • ntractor Da
gning r+i.c lnrm.l herehr eertijr + the wells)mus(H•erel rnn.c(ntaeAn+arrnrdaure with
7.is this a repair to an existing well: OYes or V^O 15.4'%'C.4C n2C.oloo or/54 NC.i C.l1-loo lf*ell Carchvaion Standards and that a co/n•
if this is a repair.ill au knnevr well construction information and explain the nature ol'the of this record has been prmdded to the+-ell nmier.
repair under:21 remar•kc sertinn or on the hack n(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 page to provide additional well construction info
construction,only i GW-i is needed. indicate TOTAL NUMBER of wells (add'Scc Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -(ft.) Submit this GW-1 within 30 days of well completion per the following:
Fw nudtiple n•cdls list all depths i illflirent(example• ,d100'and 2(d400')
40 24a. For All Wells: Original forni to Division of Water Rcsourccs (DWR),
10.Static water level below top of casing: ft) Information Processing Unit, 1617IMSC,Raleigh,NC 27699-1617
y water level isuharc casing,use"+"
6 1/18 24h. 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 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
13a.Yield(gpm) aln Method of test:
13b.Disinfection type: lor. Tabs Amount: 1 1/2 Lbs
i
Form GW-I North Carolina Department of Em ironmcnial Quality-Division of'Watcr Rcsourccs Revised 6-6.201 R