GW1-2021-06324_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
Weil Contractor Name FROM TO DESCRIPTION�'i '�"' ,—�^'ft .rl^ ft.
3271-A � 242� ft ft .
NC Well Contractor Certification Number __0
B & K Well Drilling Inc ,� f = &VUFERCASINc f6ir'u:n-ea'sedwens OR LINER tta iicabie
., FROM TO DIAMETER THICKNESS MATERIAL
Company Name t J1 �r'ta� 0 ft. / ft. 61/4 ! in- SDR-21 PVC
f6,INNER CASING OR TITBING ebtlierniai.closed ioo „_ ,„,
2.Well Construction Permit#• FROM TO I DIAMETER I THICKNESS I MATERIAL
S ft ft
List all applicable well construction permits(i.e.U1C,Cannrv,State.Variance.etc.) in.
3-Well Use(check well use): AA ft. ft in.
Water Supply Well: 17.SCREEN,
FROM TO DIAMETERV, SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑�M�unic—ipal/Public ft ft.
❑Geothermal(Heating/Cooling Supply) �sidential Water Supply(single) ft ft
ti7rlAdustrial/Commercial ❑Residential Water Supply(shared) I&GRUUP-
ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft Bentonite Four
❑Monitoring ❑Recovery ft. ft
Injection Well:
n. n.
0Aquifcr Recharge ❑Groundwater Rcmcdiation ]9;SANI)lGRAVEL PACK ittap' 'cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL- FMPLACEMENT METHOD
❑Aquifer Test ❑Stornrwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer DRILLING LOG attachadditiouid Wei&ffaccess
❑Gcothcnnal(Hcating/Coolin FROM TO DESCRI TION(c(or,hardness,sail/rock e, in size,etc.)Return) OOther(explain under#21 Remarks) ft ft r
�Q 0 43i
4.Date Well(s)Completed: fJ ,� Well ID# fit' ft It aAli n
•
5a.Well Location: 1 ft t ft f f 5an 0J
ft
rr p
Facility/OwncrNa Facility ID#(if applicable)
ft ft
Physical A dress,City,and Zip i F' ft ft
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.Certification:
N W
I ullvll
6.is(are)the well(s): .-anent or ❑Temporary g tare o i e eK_C actor Date
11
B signing this form.1lierebv certify that the ells)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or o SA NCAC 02C.0100 or 15.NCAC 02C.0200 Well Construction Standards and that a copy
tf this is a repairt,(ill out known well construction information and explain the nature q('the I this record has been provided to the well owner,
repair under21 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-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: 11/e � (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list a0 depths if different(ecnrnple-3(3a 200'uad 2@100')
40 24a. For All Wells: Original farm to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
1f water level is above casing,use-
6 1/18 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Program,1636 MSC,Raleigh,NC;27699-1636
12.Well construction method:Air Rotary j
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
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 LbS
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 R
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