GW1-2021-06322_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey `s LawATER.zolvEs
WelI Contractor Name O FROM TO DESCRIPTION
3271-A 15 ����� fL ���«
NC Well Contractor Certification Number 1"� r'�+�' ,
C=tG� -•Ott I it3UTER'CASING;for:malti�rsed wells t3ltLINER Ica hcabte
MATERI
B & K Well Drilling Inc �y�� CJt��', FROM TO DIAMETER THICKNESS AL
a�G\ al fL ft. 6 1/4 in
Company Name p SDR-21 JPVC
INNER'C'ING 0R TUBING eothermalclosed loo
2.Well Construction Permit#• gq FROM TO DIAMETERKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance.etc.) ft ft i THIC
n.
3-Well Use(check well use): ft. ft in.
Water Supply Well:
I:T SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑�Muni�ci a'l/Public ft R. in.
❑Geothermal(Heating/Cooling Supply) e�i�sidentia,Water Supply(single) A / ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1B::GROUT
❑Irri ation ❑Wells>100,000 GPD FRONT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Pour
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remcdiation
79:5AND/GRAVEL P;GK tf a --
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F.MPLACEMF.NT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG.attachaddidinalsheetsiff'
FROM TO DE,CR TION(color,hardness,soiVrock type,Ygrain size,etc.)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 RcmarksU A ft. 0 ft
4.Date Well(s)Completed: Well ID# ft eft
Sa.�`We ocation: f Oft /s ft ..nJ3�'
Ja eS �oy/) r/� (�O�p ft `T ft i �;j :r,.:•,
Facility/OwnerNamc (Jr 'f/ ( Facility 1D#(if applicable) /� ft ft
-�t'9oQ ,(rl�e, '4 a �lS ft
Physical Ad ress,Ci Ad zip n /]�j ft. ft
re�e! _ `�V° O ✓ / 21.REMAI2Ks.:
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certifi lion:
N W �.
r
t
6.Is(are)the well(s): erTrlanent or ❑Temporary Si e of Cc Ified el tractor Date
By igning this form.I hereby certify that t well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or wo I A AC'
02C.0100 or 15A NCAC 02 .0200 Well Construction Standards and that a copy
I'this is a repair,fill out knoimi well construction information and explain the nature.?l the a this record has been provided to the erll owner.
repair under"21 remarks section or on the hack 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: ( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a® -(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple isells list all depths rfdiereni(example-3@200 and 2@100')
40 249. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If crater level is above casing,use-
6 1/18 24b.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 GE!):Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b•Disinfection type: C lor. Tabs ,Amount: 1/2 LbS
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourccsi Revised 6-6-201 R