GW1-2021-01928_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey x4 avArElz= r1>s
FROM TO DESCRIPTION
Wei I Contractor Name / ft G ft
3271-A ft ft GyG
NC Well Contractor Certification Number
3,15:UTJTER'GalSING o>'jauth-cased�veUs OR�IIVER'rf'8 k w
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERI.L
0 ft. /Q' ft- 61/4 in SDR-21 JPVC
Company Name 1 >i1V`IER Cr55It+tG URA-1TStNG 'eu}iermalle'sul luo
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
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Lire all applicable well ronstructian permits(i7.e.L7C.County.State.Variance,ere.)
ft ft in
IL
ft in.
3.Well Use(check well use): AA
CRFEIsr
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in. I .
❑Geothermal(Heating/Coohng Supply) esidential Water Supply(single) L ft. in.
❑Industrial/Commercial ❑Residential Watei Supply(shared) ;18.GR'OIIT •r M•r.
❑Irri ation ❑Wei is>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Pour
❑Monitoring ❑Recovery ft fL
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Rcmediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL FMPLACFMF-N'T METHOD
❑Aquifer Test ❑Stonnwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control it ft
Z9 �
❑Geothermal(Closed Loop) ❑Tracer 13ItILLTt!1GOG`attseaddltioa3teets:dE` .:.,.:.
FROM TO DESCR T10N kolor,hardness sorVrock e, reio snze,eteJ
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft fe ed
r u :SW
4.Date Well(s)Completed: ` Well IN��7 ft U ft /Qi✓�
ft D ft `
Sa.Well Location:
l'o MGn� (�f/I'�Si7YI1Vt/'t/••� ft l00ft
Facility crNamc Facility ID#(if applicable) �)ft.
lay C By�'t�✓`a�e, oa SG�IIe,�,C, �I ft ft
Physical AdOress,City,and Zip
County Parcel Identification No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: Ii two 11.13t On t�UVU' 'Section /
N W II
e of enifued ell Contrac Date
6.Is(are)the well(s): ermanent or ❑Temporary f
y signing Chic form.I herebi,cer that the nrell(.$)xns(were)consinicted in accordance with
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7.Is this a repair to an existing well: ❑Yes or �i+'V 15A ArCAC 02C.0100 or 15A NCAC 02C,.0200 Well Conusn uction Standards and that a cops
If this is a repaint fill out knoxvn well constrnclion information and explain the nature of the of this record has been provided to the well owner.
repair under:.'21 remarks section or on the back of this form. 23.Site diagram or additional wellAetails:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See Ovet in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '20 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple nrells list all depths if different(example-3 • 00'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DR),
10.Static water level below top of casing:40 (ft.) Wlnformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
)/'neater level is above casing,use
6.1/18 24b.For Injection Wells:Copy to$WR,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 WellsproducinQ over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
lor. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Revised G-6-301 R
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
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