GW1-2021-06325_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey "`.►�"°" a.vvAR:zorl>s ...
Well Contractor Name FROM TO DESCRIPTION 1
't / ft [ rt yf�rf�I 'm t e �L'
3271-R t-p ��re�p��� a 30 fL ft- In e "1� vt'G
NC Well Contractor Certification Number FROM TO DIAMETER THICK
� CoG"�' � iS..QUT£R'CASlllGforinulti-cased wells't7RLii)T€R Kfa "1e
B & K Well Drilling Inc it t�i0�� 4� NESS MATERIAL
0 ft. g(ft. 6 1/4 in: SDR-21 PVC
Company Name
I V j 1G'IN�iMCASI G"OR Fif$Zl�t@ eother u diisedl`
2.Well Construction Permit#• �_ j j� �lj FROM TO DIAMETER ' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counna State.!Variance.etc.) f. ft tn-
3.WeU Use(check well use): AR
IL ft in,
Water Supply Well:
pity FROM TO DIAMETER SLOTSlZE THICKNESS MATERIAL
OAgricultural OMunicipai/Public ft, ft. in.
OGeothermal(Heating/Cooling Supply) Vd-ential Water Supply(single) fL in.
Olndustrial/Commercial OResidential Water Supply(shared) I&GROUr
❑hTi ation O Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite, Pour
OMonitoring ORecovery ft ft.
injection Well:
ft ft
OAquifcr Recharge OGroundwater Remediation
I9..SXND/GRAV..ELPAG:K ifi ble
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
OExperimental Technology OSubsidence Control ft ft
OGeothermal(Closed Loop) ❑Tracer ©).DRiLL1NG'1 OG ettscltsddfoonal:slieefsii -
FROM TO DESr iP N(color,hardness,soitltock p e, in size,etc.)
OGcothcnna!(Hcatin Coolin Return) OOthcr(explain under#21 Remarks) 0 ft �t.J ft ! 0!
4.Date Well(s)Completed: Well iD# ft {eft i f
5a.-Wee�l-1 Location: Q ft e r "4'g 7
ft ft 4* if L_
Facility/OwncrNamc Facility fD4(if applicable) ft. ft
I3Y n'1o' 1 r S�i�il�e,� (���9� ft ft
Physical A dress,City,and Zip fL %
:2�7 jell co-
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification: P
6.Is(are)the weil(s): L9f'ermanent or OTemporary St ure of ified We Convector Date
signing is faun.1 herebi.certify arthe well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: Oyes or ONO r 15,4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a cony
/f this is a repair.fall out knomi well construction infonnation and explain the nature gfthe of this record has been prorided to the well owner
repair under»21 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: j 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-i within 30 days of well completion per the following:
For nraltiple hells list all depths 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: ((i) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use-+"
6 1/1$ 24b, For Injection Wells:Copy o DWR,Underground Injection Control(TUC)
I l•Borehole diameter: (in.) Program.1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and Ogee-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d For Water
Wells producing over 100.000 GEL):Copy to DWR,CCPCUA
Mit Program
13a.Yield(gpm) ethod of test: -1611
Air Lift Perm
13b.Disinfection type: C' lot. Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018