GW1-2021-06326_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
14.WAT-ER20NES
Well Contractor Name FROM - TO DESCRIPTION*
3271-A e ffiPt. I yi� IL 17,�e-
Tyft. ft. 4f4e �r4-4;ralc Al;1 e
NC Well Contractor Certification Number it(1,
1 11
OUTER CASING`(finj uuil&��waill
B & K Well Drilling Inc FROM I TO DIAMETER P rc!]TM� I MATERIAL
Company Name 0 16 1/4 !In- ISDR-21 JPVC
16.FTNER , ING:OR TURNG(6iithei�sl.
2.Well Construction Permit FROM I TO DIAMETER! THICKNESS MATERIAL
List all applicable Kwl/construction permits(i,e.UR Connrv,Stare.Variance,cu..) ft. ft in'
3.Well Use(check well use); ft in.
Water Supply Well: .114 SCRREW
FROM TO DIAMETER :SLOTSIZE THICKNE S I MATERIAL
OAgricultural OMunicipaVPublic it ft. in.
OGeothermal(Heating/Cooling Supply) CRU"id—ential Water Supply(single) fL ft.
01ndustrial/Commercial OResidential Water Supply(shared) ROUT
Oirrigation OWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 20 ft- 18entonite Pour
OMonitoring ORecovery ft. ft-
Injection Well: ft it.
0Aquifcr Recharge OGroundwater Rcmediation 19.SAND/GRAVEL PACK afamu cable
)
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I FMPLACFMFNT METHOD
DAquifer Test OStormwater Drainage ff. ft.
OExperimental Technology 13 Subsidence Control ft. ft.
OGeOthermal(Closed Loop) OTracer IJXGL0G:(attac1i0iddI ii_I:chq4vJf
DGrothcrinal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM ft. TO I DESCRIPTION(color,hardness,soitfrock type.givin Sim etc)
10 /4fl Red 15—
4.Date Well(s)Completed: G7r i Well I D# 5r-f- 35- 'L B r.,41,ql_Q,
ffro
Sa.Well Location: Tr ft' 5-ft 74";;74 l-l�l
1)1— a
61;oJ,1_11417 11*h1ef ft. _J4,?A/,5.6r,
Facility/Owner Name Tacility��(if applicWc)
/,ser 'j,VJ73eo�naal 5 7� it- ft.
Physical Address,City,and Zip ft ft
3 e
ZL-RE.MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fattlong is sufficient) 22.Certijication-
N W A.J- j 1V/?1Vt
Date 1
6.Is(are)the well(s): Veermarrent or 01remporary Tl,(Kature ferillf&'Welf Co cr r
I'signingthisfionn.Ihere ,, rd that the tivil(s)was(were)ctinstructedin accordance ii-ith
I ;IACfyr
7.Is this a repair to an existing well: Oyes or 5.4NCACO2C.0100orl NCAC 02C.0200 Well Construction Standards and that a copy
tf this is a repaip,fW out known wellconstrucitan 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 qftliLsforn 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having,die seine You may use the back of this page
e 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 arrach additional pages if necessary,
drilled:
_Lle 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ') -7_� _—(ft.) Submit this GW-I within 30 days of well completion per the following:
For�multiple wells list all depths if different(example-3 @2 00'and 2 @ 10 0')
40 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing- — (ft-) 1,formatior.Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
)Grater level is above casing,use"+'*
I I.Borehole diameter:6 1118 24b.For Injection Wells:Copy?to DWR,Underground Injection Control(TUC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 214c.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 WeIIihrodMWV00 000 GPD-Copy to DWR,CCPCUA
13s.Yield(gprn) J-0 9AA4 Method of test:Air Lift Permit Program.!611 C 27699-1 61 1
13b.Disinfection type: 6hlor. Tabs Amount; 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourices Revised 6-6-201