GW1-2021-06518_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD �G -, For Internal Usc Only':
I.Well Contractor Information:
Joseph Bailey fy9 v V •,�L 14.WATER ZONES
FRONT TO DESCRIPTION
\1'cllContraaorNamc �� ,at7��c O^ f[. ft.
3271-A
ft
NC Well Contractor Certification Number tioti� 15.OUTER CASING for multi cased wells OR LINER if a tinble
`� ~ FROM TO UTANtEt'ER THICKNESS MATERLAI.
B & K Well Drilling Inc ,r,�' 0 ft- �` rt. 16 1/4 s R-21 JPVC
Company Name �/� 16.INNER C.451NG OR TUBING eo[hermal dosed-loop)
FRONT 'I'O UTAME'I'ER THICK�k:S.S MATERIAL.
2.Well Construction Permit#: ft. ft. in.
List all applicable Nell(-nn.w,tit tine ye nti s(i.e.C•1C.Crmmnt S'tnie. f orianre.etc l
in-
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FRONT TO DIAMETER SLOT 517.E TIII(KNESS MATERIAL
OAgricultural ❑Muni al/Public tt. R. in.
OGcothetmal(Heating/Cooling Supply) esidcntial Water Supply(single) ft. It, in.
OlndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FRONt TO MATERIAL
❑IITI anon ❑\yells> 100.000 GPD
EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite Pour
Oivtonitoring ORecovery ft. ft.
Injection Well: rL ft.
❑Aquifer Recharge OGroundwater Remcdiation
19.SAND/GRAVEL PACK tif a ucable
❑Aquifer Storage and Recovery ❑Salinily Ban'ler FROM TO aIATERIAL. t:MP1.nCF.MF.NT atET11UD
Aquifer Test
❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control
OGeothennal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessa
FRONT TO DESCRIP ION(color.hardness.soiVrock type.grain size,etc.)
OGcothcnnal(I-lcatingiCooling Rcttui-) ❑Other(explain under�'21 Remarks) fL ft. 41
4.Date Well(s)Completed:
Vol / Well 1 D# / 45 ft.
f[. ft.
5a.Well Location:
�Adlwf GGG 4Facilitylk ft. ft.
ti c(ifapplicable) f[ ftFacilitylOwnerNamei�
ft. ft.
ICAy
Physical Address.City.and Zip
,+J�s (\�/1�L _ l i^/s/�ID� / •`+ 21.REMARKS
County -Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal dcgrcesr
(if,ccll field,one latrlong k sufficient) 22.Certification:
N "
Sin re of Cet tc a ontracio Dat
6.Is(are)the well(s): manent or ❑Temporary
/ Br it;,tinq dtic)'arm.!herehr cenifi,hat !re ue/ILU,(ac here)<nncn-arteAin nrrnrdm,ce,rith
7.Is this a repair to an existing well: ❑Yes or i;j�7ia/ i i.4.\'CAC(12C.0/fln m /j.a:\'C.( I ..n.nn If'e//Cnncnvctinn SrmtAurdc and N,nr a cape
n rhi.c re,,rd has hoes p,rrr,-,ded m the,(•ell nN e,
/J chic is a repair.fill 0111 ktrnNot Nell crnult uctinn information and e.rploi++the uanur n/the /
repair under 21 remm-kc sectinn or o,t the hack of chic form. 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 haying the same (add'Scc Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q oc' (ft.) Submit this GW-I within 30 days of well completion per the following:
Fur nurhipla yells list all depths it di/jerew(example-3ra 200'and 26. on')
24a. For All 'Fells: Ori.-inal form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft*) Information Processing Unit.1617 MSC.Raleigh.NC 27699-1 61 7
1%,role,lerel is aholy rasing.use"+
6 1/18 246. For Injection Wells:Copt'to DWR, Underground Injection Control (IL•C)
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.anger,rola,y..cablc.direct push•etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For water��'ells producing over 100,000 GPD:Copy to DWR,CCPCUA
132.Yield(gpm) Method of test.
Air Lift Permit Program,1611 MSC,Raleigh•NC 27699-161 1
tlo*rTabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Rc.scd 6-6-20IR
Form G\V-I
North Carolina Department of En6onmcnial Quality-Dicieion o? It-i'urces ,