GW1-2021-06514_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey FROM
ER ZONES
RO>1 TO DESCRIPT70
WcII Contractor Name ft. ft.
3271-A ft. ft.
NC Well Contractor Certification Number 15.OUTER.CASING for multi-cased welts OR LPVER d.a lieable
B & K Well Drilling Inc FROM TO DIAMETER THICK\ESS MATERIAL
0 ft. , .ft 6 1/4 i" SDR-21 PVC
Company Name ^ �1�1� FROM
M INNER CASING OR TfJBINM evthet ntalcl ICKNIoo
AJ FROM TO DIAMETER THICK\ESS MATERIAL
2.Well Construction Permit#: ft• ft. in.
List all applicable well Construction permits(i.e.GIC,Connn',State.Variance.etc.)
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural
OMunicipahPublic fL rt. in.
OGeo[hertnal(HeatingiCooling Supply)
ential Water Supply(single) ft. ft. in.
❑Industrial/Cornmercial ❑Residential Water Supply(shared) .18.GROUT
❑W el Is>1007000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non- anon 0 rL 20 It- BentonitePour
Non-Water Supply Well:
❑Monitoring
ORecovery tt' ft.
Injection Well: ft• I ft.
Recharge ❑Groundwater Rcmcdia[ion 19.SAND/GRAVEL PACK if a "cable
OAquifer Storage and Recovery OSalinity Barrier FROM ft.
TO ft.
MATERIAL EMPLACF.MF.N'T MF.THUD
OAquifer Test ❑Stormwater Drainage
GSubsidence Control ft. ft.
Technology ,
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLI- LOG attach additionid sheets if necessary)
FROM TU DESCR TION(color,hardness.sotock e,gain size etc.)
OGcotlicnnal(Hcating/Cooling Rcrum) OOthcr(explain u/nder#21 Remarks) ft. ft.
4.Date Well(s)Completed:
We111D# L 'Ir (D Q ft. ft.
ft. It. 1tov /I
5a.Well Location:/ ft. ft-
Faciliry/OwncrName (•p Facility D (ii'applicablc) G ft rt
ft. ft ft.
?/� d 'SrJ�� Nl..�I
Physical d ress,C /YJoa�
Liity,and
27.REMARKS r�
oun[y
Parcel Identification No.(P1N)
c �^• �a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer Cation'
N �r
a urc of ertifie I Con c Date
er
6.Is(are)the well(s):. mancnt or OTemporary
1:signing rha farm.I hereby cer that the hell(.)was(were)constructed in accordance with
5A AZAC WC.0100 ar 1 SA NCAC 02C.0200 R ell Consnvctian Standards and that a copy
7.Is this a repair to an existing well: ❑Yes or of this retard has been pmiaded ro the well owner16
If this is a repair.Ill our known%,ell construction information an erploio the nature of the
repair under.,21 remm•kr section or an the back of this fomi' 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer (ft') Submit this GW-1 within 30 days of well completion per the following:
Fa multiple wells list all depths if different(ex(anple- @200'and 2(a)100') f
40 24a. For All Wells: Original form to Division of Watcr Resources (DWR),
I O.,Static water level below top of casing: (ft.) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If truter level is aboi:e casing.use"+
6 1/18 24b. For Infection Wells:Copy'to DWR.Undereround Injection Control(TUC)
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 prodticin,over 100,000 GPD:Copy to DWR,CCPCUA
Q Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type:
chilor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-3018
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