GW1-2021-06516_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) _ For internal Use Only:
1.Well Contractor Information:
%
Joseph Bailey FRWATER ZO1 DESCRIPTION
W'cll Contractor Name �O �� / ft. ft
3271-A �� ��� y0 it. ` K4 ft r) 2G�'Jd
cz.,00
NC Weil Contractor Certification Number \ �}t0 ��• 15.OUTER CASING for mukf-cased wells OR LINER(if a licable
P e�(�j� FROM TO DIAMETER THICKNESS MATERIAL
B & K Well Drilling Inch_ 0 ft, h ft. s 114 i SDR-21 JPVC
Company Name �� a`r�� 0 16:IN`1ER C. ING OR TFaXG euthertrtal closed lbo
�j7r) FROM Tp DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: a ft ft in
List all applimble well construction permirs 6.e.UIC,Counn.,State.Verinn' etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural
❑Munic' /Public ft ft. r"'
❑Geothermal(HeatingiCooling Supply) esidential Water Supply(single) t ft. in.
❑Indu m
strial/Comercial ❑Residential Water Supply(shared) 18.GROUT
ClWells>100,000 GPD FROdt TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri anon 0 ft 20 fL Bentonite Pour
Non-Water Supply Well:
❑Monitoring ❑Recovery
ft. ft
injection Well: ft ft !
❑Aquifer Recharge ❑Groundwater Remcdiatio" 19.SAND/GRAVEL PACK if a it cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO EMPI.ACEMF-,T hIETHOD
ft. fL
❑Aquifer Test ❑S[ormwater Drainage � -1
❑Experimental Technology
❑Subsidence Control ft. fc
❑Geothermal(Closed Loop) ❑Tracer 2 .DRILLING LOG(attach additional sheets if cecessare
FRUM TO DESCRIPTI N(color.hardness,soiUrock t. e, rain siu,etc-)
❑Gcotllcnnal(Hcatin�Cooling Return) ❑Other(explain under#21 Rcinarks) ft- 6 ft 1L 61
10 I
Well /eT3 it. D ft i
4.Date Well(s)Completed: /i✓►Is/�
v ft ft
5a.Well Location: ft. D ft oy
AkCA! � 'n
.l ft. ft.
Faciliry!OwncrNamc �Facility lD='(ifapplicable)
� G/
� � r7` /TlN"f�G� /Y/ rI�1I�a.Of(Jr1 ft. if ft. C
ft. �J ft
zu,
and Zip
21.REMARKS
County
Parcel Identification No.(PTN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat'long is sufficient) 22.Cer'rcation:
N W a�
Si a[ure Certifie ell C trot Da
6.is(are)the well(s): ermanent or ❑Temporary
r signing this form.1 herehr cernfy ihaz the❑•ell(,t1 wcls(were)rnnstnuved in accordm+re with
7.is this a repair to an existing well ❑Yes or � SA A'CAC l/2C.fll/l(1 or 1�A NCAGOIC.r1200 Yell Cnnsnvuia+Standards and that n cant
of this record has been provided to the well owner.
or this is a repair..ill out known+well construction inforinatinn and explain the nature nJ the
repair under i.21 remarks secrim+or on the back of thLt form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
3.For Geoprobt/DPT or Closed-Loop Geothermal Wells having die same (add'See Over''in Remarks Box).You may also attach additional pages if necessar'.
construction,only 1 GW-i is needed. indicate TOTAL NUMBER of wclls
drilled: � � 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
For nudtiple wells list all depths ifdi(ferent(example-3@200 and 2(4100'1
40 24a. For All Wells: Original.form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) lnformation Processing Unit,1617 MSC,Raleigh,INC 27699-1617
if waier level is above casing.use"+
6 1/18 24b. For injection Wells:Co(y to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) Program. 1636 MSC.Raleigh,NC 27699-1636
Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
12.Well construction method: -
Ii.e.auger.rotary,cable-direct push.etc.) county environmental health department of the county where installed
ter Wells produc`ina over 100,000 GPD:Copy to DWR,CCPCUA
FOR WATER SUPPLY WELLS ONLY: 24d.For Wa
��✓�_
Air Lift Permit Program.1611 MSC,Raleigh,NC 27699-16
13a.Yield(gpm) Method of test: 1 1
Chlor. Tabs Amount:
1 1/2 Lbs
13b.Disinfection type: -
Form GW-I North Carolina Department of Fn%-ironmental Quality-Dicicion of Water Resources
Revised 6-6-201 R