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Home My WebLink AboutGW1-2021-01927_Well Construction - GW1_20210404 ay � WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Joseph Bailey I4.'WATER7ONESeq FROM TO I DESCRIPTION Well Contractor Name qJ ft ft // (. v(e_ e 3271-A fL /r ft a o7,P'iC- NC Well Contractor Certification Number IS.OUTER;CASiNG'for moth1. cased:'S QR LiNPR<da "lieable B & K Well Drilling Inc !nfii DIAMETER THICKNESS MATERIAL I ft. 61/4 i" SDR-21 PVC Company Name � FROM INNER,CASING TO OR.TIJBING, eutl erma7 closed-1uo FROM ETER K\ESS MATERIAL_ 2.Well Construction Permit#: ft. fL DIAM in• THIC List all applicable well construction perm , .i e.WC,Coun(v,Ttate.Variance,etc.) ft. ft in. 3.Well Use(check well use): 17.SCREEN,.. Water Supply Well: FROM T I DIAMETER SLOTSIZE THICKNESS MATERIAL ❑Agricultural ❑Mun l/Public ft. ft. in. ❑Geothermal(Heating/Cooling Supply) esidenl,.l Water Supply(single) fL ft. in. ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Irri atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft. 20 ft- Bentonite JPour _ ❑Monitoring ❑Recovery ft. It. Injection Well: ft. ft ❑Aquifer Recharge ❑Groundwater Remediation 19,.SAN1D/GRriYEL.PACK fa licalile , ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Test ❑Stormwater Drainage fL ft ❑Experimental Technology ❑Subsidence Control ft. ft Geotheal(Closed Loop) ❑Tracer fl:BRILLINGLOG attar;additionallteetsifneeess ❑ rm FROM TO DESCRIPTION(color,hardness soiVrock e,gritin s,:,etc.) " ❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) fL fL 4.Date Well 0 ft ft. $)Completed: � � Well ID# _ 141 fL //i) ft 5a.Well Location: I j�� J 'N Ge_ �fl/SI!/r�i( .Y6I` ft. ft I Faci�Ow� � Facility ID#(if applicable) STIL % G/ Physical Address,City,as d Zip w JY �I ram z•. - d � County Parcel Identification No.(PiN) r 4 2021 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certific 'on: �) W^ l;a 0y; � N W '4{Z��^1,Oi1 Sign of rtified e I Contracto Date 6.Is(are)the well(s): rm eanent or ❑Temporary By igning this form,1 hereby cert that the nrll(s)was(were)constntcled in accordance with r'� I A NCAC 02C.0100 or 15A NCAC 02C_0200 Well Construction Standards and that a copy 7.Is this a repair to an existing well: ❑Yes or this retard has been provided to the xrf!owner. If this it a repair,fill out know;+well construction information and explain the nature o f the oj repair under 21 remarks section or on the back of this form. 23.Site diagram or additional well details: 8.ForGeoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info (add'See Over'in Remarks Box).You may also attach additional pages if necessary. construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells drilled: 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: Q� (ft') Submit this GW-1 within 30 days of well completion per the followin^: For multiple wells list all depths if different(example-3@200 and 2@100') 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing:40 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 water level is above casing,use"+" 611/18 24b.For Injection Wells:Copy to;DW R,Underground injection Control(TUC) 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 13a.Yield(gpm) Method of test: Air Lift Permit Program,161 1 MSC,Raleigh,NC 27699-1 61 1 tor. Tabs 1 1/2 Lbs 13b.Disinfection type: Amount: k Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only: 1.Well Contractor Information: ''i' .•'CSiis:ii;itiii::iii;i::: Alfred Kiesling Sr 4.� -� Zfl1 FROM TO DEtGRFPTIO� Well Contractor Name 2670-A �" 3` a t. ft. ft. NC Well Ctn,nactor Certification Number fedvuitltl L'14CiI'::, OR'31NFt2 B & K Well Drilling Inc FROi%l TO 1}1.AVETER THICKNESS MATERLAL 0 n C$ fu 6 1/4 in SDR 21 PVC.. Company Name 4G::I1vN£Dba~aSIIe1G i� G:'eagtezmel teased-•. �` ) (^} FROM 70 InAMETER THICKNESS MATERIAL2.Well Construction Permit#: C� -"I ) ! 55_",` t isr all applicable well construrCion permit r.e.&C.Cotow.State.kariance.die.) €t. ft. in. 3.Well Use(check well use): ft. fL in. Water Supply Well: ...... PP Y FROM .. TO DIAMETER slot SIZE.. THiCKNES,S MST£RIAL D3Agrie utttital DM icipaUPubtic ft. tt in. ClGeothetmal(Heating/Cooling Supply) esidential Water Supply(Single) ft. tit. in. Supply 0lndustnal.Conmzeresal ORessdanDai Water (shared) Oirri ation OWells>100,OOOGPD FROM TV MATERL&L EAtpLACE NT niETftVD.&.4;tOUMT Nun-Water Supply Well: 0 it 20 ic• Seiltonite Pour Oklonitoring ORccovcry ft. ft. Injection ir4•etl: ft. ft. OA uifer Recharge DGrouudwater Remediation - .'3+�:&aall�Cit�Y�..i*+I(•.�`f�••:•::..r. to .. .. . DAquifer Storage and Recovery DSalinky Barrier FROM TO MATERIAL F.MPL.ACEWNT METHOD OAquifer Test ! OStormwater Drainage ft. ft. OExperimental Technology OSubsidence Control fe. ft. OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION tuolor.d nets oGeothermal(Heatkat Remarks)Return) OOther(explain under#21 Remar s) sn;t rock era;n tee i 4.Date Wells)Completed: I Well ID# ft. ft. 'JL S ft. ft. Facility/Owner Name t } Facility M.'(ifapplicable) Physical Address,City.and Zip County Pa_'ccl Identification No.(PIN) s e _„ rf i rnJ�,�y31Iti. Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees; r I'eacte 41 pj (it'wcli ticid,one ia`long is sufficient) /2.Certification: 6.ls(are)the well(S): C1Permattent or DTemporarp Sign ure ofCertitier:well Contractor Dare Bt•signing rh&form.I hereAr r ertili that the wrll(sl eats(i+err)rvnslrucred in rr(,•ordance uirh 7.is this a repair to an existing well: DYes or (No 15A.VC 4C 0?C At00 or 15.4 XCAC 02C.0100 It'elt Cosrcrrvtxiva:Standards and that a Copt !j'rhis s a repair.fill out known well ronsrnmion injonnotinn and plain the nave nfrhe of this record has brrn prorided m rhr vrll owner. repair raider#21 remarks section or on the back ofthis farnr' •Site diagram or additional weII details: 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional w=ell construction info construction.onlv_J,,l3W-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Be-,).You may also attach additional Pages if necessary. drilled: jE � 24.SUBi9 MAL INSTRUCTIONS 9.Total well depth below land surface: Jft Submit this GW-i within 30 days of well completion per the following: For nadriple wells list all depths ii(differenm(i temple-3(ar_00 and 2@1007) 24a. For All Wells: Ori;iaat form to Division of Water Resources (DWR). 10.Static water feel below top of casing:�� (ft) Information Processing Unit1617 MSC.Raleigh.NC 27699-1617 1 j voter leer!is Whore ca;;irig.'�i'e`'+" 11.Borehole diameter:6 1/8 (in.) 24b•For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 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 enz•ironmental healtb`deparlment of the county where uLswied FOR WATER SUPPLY WELLS ONLY: 4d For Water Wells producing over t4(i,000 GPD:Copy to DWI2,CCPCUA �] Air Lift PermitProgrant,1611 MSC;Raleigh. -C27699-1 61 1 13a.Yield(gpm) U` Method of test:tab•Disinfection type:ChIOr. Tabs Amount: 1 1/2 Lb s 4 j Foray GW-I North Carolina Department of En6ronmcntal Quality-Division of Waror Rccourccs R_vise:d 6-6-201A