GW1-2021-06324_Well Construction - GW1_20210915 (2)

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
FROM TO DESCRIPTION
Well Contractor Name ft.
re /0
3271-A L% \ fL ft
NC Well Contractor Certification Number
156'OUTER CASING"(for'.,�mtilti-ca�std*iffls) �JMAkTERIAL
B & K Well Drilling Inc FROM I TO �Al_,A�MVETEWI al
PVC
Company Name Ic Vcwiti OR
2.Well Construction Permit#: DIAMETER!FROM I TO I DI I THICKNESS I MATERIAL
in.
List all applicable well constivrtion Permit.,(i.e.UIC Callan.State, Variance,etc.) fit. =
in,
3.Well Use(check well use): Jir
17.SCREEN:�.
Water Supply Well: FROM TO I-DIAMETER 1,SLOT SIZE I THICKNESS MATERIAL
o
OAgri'cultural D;M aVPublic ft. I in.
.�un fli
'c''c
OGeothermal(Heating/Cooling Supply) d.nual Water Supply(single) • in-
OlndiLstrial/Commercial oResidential Water Supply(shared)
Oft-rigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMIOUNT-
0 111 20 fL
Non-Water Supply Well: M�n Bentonitia Pour
OMonitoring ORecovery f1i ft.
Injection Well: ". I It-
0Aquifer Recharge OGroundwater Reinctliation 77:7:7777777:77=r
.19:SAND/GRAVEL PACK'ff- WY
DAquifer Storage and Recovery OSalinity Barrier FROM _ TO MATERIAL
OAquifer Test oStormwater Drainage
OExperimentat Technology OSubsidence Control ft. fL
DGeothermal(Closed Loop) oTracer
FROM TO DESCRIPTION'(color,hardaess.sail/rock qrli in stze„etc.)
❑Gcothcnnal(HcatinglCooling Return) 00thcr(explain under 421 Remarks) 0 ft. `L deii 5611
& i
4.Date Well(s)Completed: Vzffov Well ID# e7-74 V ft. fL rotili %ii OW
5a.Well Location:
ft.
tc Cki, ?a
F fli '0i Facility ID4(if ali Zee., ft
aci i m j r
!09
o;??6. 9::�Ili 1*71C
as
Physical A dress,City,and ZIP
1/�2/ q M E REARKS-1:
Co.
County fication No.(PrN) sell 'vWC-i 4cdo1W__ oO rs�e
Parcel Identi
Z'As a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: s
(if well field,one lat/long is sufficient) 22.Certffivtion':
N W _q Al LL-JAd it
Co
n t
ell Co&n
6.Is(are)the well(s): l0wrManent or OTernporary Si, aft. r1l te Mat
-cordance with
. signing this form.I _e ify that the wells)was(were)constructed in ac
7.Is this a repair to an existing well: 0yes or VW1__ 15A NC,4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
01this is a repair,fill out known well coostniction infonnatinn and explain the nature of the of this record has been provided to the ii-ell owner
repair under"21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0?05-" - - (ft-) Submit this GW-1 within 30 day s of well completion per the following:
For multiple wells 16t all di if different(example-3@200'and 2@ 100')
40 24a. For All Wells: Original form to Division of Water Resources; (DWR).
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 1 MSC,Raleigh.NC 27699-1617
If irate,level is above casing.use
61/18 24b.For Injection Wells-Copy to,DWRI Underground injection Control(TUC)
I I_Borehole diameter: Program,1636 MSC.Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Sunply and Omen-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 oroducin I I MSC, g over00
2 9:,GED:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air Lift Pennit Program,16 Raleigh,NC 2V 611
—S
13b.Disinfection type:?hlor. Tabs Amount: 1 1/2 Lbs
Form GW-i North Carolina Department of Environmental Quality-Division of Water Rcsou re(I-S Revised 6-6-20 18