GW1-2021-01931_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD(GA-1) For internal Use Only:
1.Well Contractor Information:
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Joseph Bailey 1a:WaT>exzt»1vFs
FROM I TO V DESCRIPTION
Well Contractor Name 31ft ft Art, e
3271-A
NC Well Contractor Certification Number ag`pZI4FEI>GASIN #urmai6Lesed*ah Oitilsi�lER'rf'a' heable :,
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. t!' ft• 6 1/4 i" SDR-21 JPVC
Company Name
I&Il1P1ER,CASI1!ICsORING eotherma7clesie�lou
2.Well Construction Permit#• FROM I TO A. I THICKNESS I MATERIAL
List all applicahle well construction permits(i.e.U1C.County,State.Unrinnce,etc.)
ft ft m
ft ft , in-
3.Well Use(check well use):
Water Supply Well: FROM I TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. i"-
❑lndustrial/Cortunercial ❑Residential Water Supply(shared) a _rs
❑Irri ation ❑Wells>100,000 GPD FROM TO M.ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It 20 ft Bentonite Pour
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge DGroundwatcr Rcmcdiation
7?S tNA/GRi4!EL PAC1 a hcable
q ty g ft ft FMPLACFMFN'T METHOD
❑A uifer Storage and Recovery ❑Salim Barrier —FROM To MATERIAL
❑A uifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control tt ft
❑Geothermal(Closed Loop) ❑Tracer Z873RiLLING3vOG attaciraddittalacheec+f "
j#X
TO DESCR TiON(color,hardness,soii/mck e, m Ale.etc.)
Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft��� Well ID# O 7ft 4.Date Wells)Completed: QfL
Sa.We11 Location:�Q��� !lld ftFacilt/OwnerNamc Facility ID#(ifapplicable) ft
of
ft ft ' t t
Physical Addr ss,Ci aid Zip --
_!,✓. �lo' i Y z1( 1`IARxsn: ;>
'ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r rwuOLy ;t• , t t
(ifwcll field,one lat/long is sufficient) 22.Certification
ul
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N WA@ ,
Sign a of rtifte ell C n ctor D e
6.ls(are)the well(s): rmanent or ❑Temporary
signing this forun.I hereh,c rtify that the scell(.$)x•as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Q� 15A NCAC 02C.0100 or 1 NCAC 01C.0200 Well Constmctiour Standards and that a copy
If this is a repair,fill out knomi well construction information and explain the nature of the of this record has been provided to the xrll owner.
repair under s11 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 page'to provide additional well construction info
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:�p (ft') Submit this GW-1 within 30 days of well completion per the following:
For nudtiple n'ells list all depths ifdii ferent(example-3(r 0'and 2@a 100') '
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 2 7699-1 61 7
/f waler level is above casing,use
6 1/18 24b.For Injection Wells:Copy to'DWR,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
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield Wm) Method of test:
13b.Disinfection type: G"M or. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of water Rcsour M Revised(r6-201 R
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