GW1-2021-06416_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) T or Internal Use Only: k
1.Well Contractor Information: j
Joseph Bailey 1a.wirERzoxEs.: _...
Name FROM TO DESCRIPTION
Well Contractor (eft �rhl ft
3271-A
ft ft
NC Well Contractor Certification Number I
15.OLT1'£RGA5R4G formuiti-casedwells'OR'TiTi1TER if`-.
B & K Well Drilling Inc FROM TO DIAMETER ! THICKNES5 MATERIAL
0 ft fXft. 161/4 in SDR-21 JPVC
Company Name j
��� oil{s� 16.Uq-7%R.ens]NG-0R.TUBING l;em. R-4asea loo :w
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well constrvcrion permirs 0.e.UIC.Counn'.State.Variance,etc.) ft. ft in.
3.Well Use(check well use): IVA ft. ft in.
Water Supply Well: —FROvt TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. ft. in.
❑Geothermal(HeatinglCooling Supply) esidential Water Supply(single) j Mkt
01ndustrial/Commercial CResidential Water Supply(shared) 18:GROUT
Otrri ation O Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Pour
❑Monitoring ❑Recovery ft ft
Injection Weil:
t4 ft
❑Aquifer Recharge OGroundwater Rcmediation
19.:SAND1GRAtVELPACK it _ k
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. I F.MPLACF.MF.NT METHOD
DAquifer Test OStormwater Drainage ft ft
OExperimentai Technology OSubsidence Control ft ft
OGeothermal(Closed Loop) OTracer XDR�vOG`aisachsilitltfgnalaCieeisif
FROM TO DESCRIPTION color,hardness,soli rock e,g in size,etc.
OGcotltcrmal(Hcating/Coolin Return) OOthcr(explain under 421 Remarks) ft / ftfiel r
4.Date Weii(s)Completed: )t��� Well iD# U ft ft / 4lr17 SOJ
5a.Well Location: ft ft ( /f�� 'N f�+d,
5 ail ft GS' ft fit " v�fl" 12oGk
Facility/OwncrName Facility iD9(ifapplicablc) ft t ft3q�Jt� f �a,
I'0$,5-I�dlliqu/DZk� IC/f. /1�i'1Y)tt��}�t� _ ft ft #
Physical Address,City,am Zip t ft ft
C�Qw'0n 60- 21.RE rARxs .�
County Parcel identification No.(PiN) ZVLA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rct.` t�t111
(if well field.one fattlong is sufficient) 22.Certification: �;f; §1;,`1i+`)NR
sonjlpiS /
N W �� f I
6.ls(are)the well(s): rmanent or OTemporan Sig c of nified well Con for pate !
B signing this(arm.l Jrerehv cerr.r at the tvell(sJ Kns(were)rnnstntcted in accordance with
7.Is this a repair to an existing well: ❑Yes or �r 1 A NCAC 01C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction information and explain the naturetif the of this record has been provided to the}tell owner
repair under=11 remarks section or air the back of this form
23.Site diagram or additional well details:
g.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: ( �� (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple[.ells list all depths if different(example-3@200'and 2L100')
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 MSC,Raleigh,NC 27699-1617
q water level is above easing.use
6 1/18 24b.For Injection Wells:Copy to DWR,Underground injection Control(iUC)
l 1.Borehole diameter: tin•) Program,1636 MSC,Raleigh.NC 27699-1636
12.Well construction method:Air Rotary Program,
For Water Suppiy 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
5✓' Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-Ibl l
13a.Yield(gpm) / Method of test:
i
13b.Disinfection type: Ghr. Tabs Amount: 1 1/2 Lbs
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcm Revised 6-6-201 A