GW1-2021-05435_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD (GW-1)
For internal Use Only:
1.Well Contractor Information:
,a.wATERZONEs
Joseph Bailey
—.11 w,- AIPTIU
FROM TO DESC �
Well Contractor Name � `.d tip 0
ft.. t
3271 21:-A o fL
NC Well Contractor Certification Number J 15.OUTER CASING for m"Idtased wells OR LINER i(a ficatile
OC� OV It FROM TO DIAMETER' THICKNESS MATERIAL
B & K Well Drilling Inc „ , c✓essln9 0 ft. ,'rt• 10 1/4 SDR-21 !PVC
tt�tC"3t` r J Jet
Company Name 1C D� t� INNER CASING OR TUBING(e°thertnal closed too
M1?ATER1.4
FROM TO DIAMETER THICKNESS
FROM
2.Well Construction Permit#: •t. ft.
!7 in.
List all applicable well construction permits 6-e.UIC,Cmtnn•.Stare.Variant¢,erci l
ft. fL
3.Well Use(check well use): 17.SCREEN
Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Water Supply ft. ft. in.
❑Mumc he
❑Agri cu Rural i
esidential Water Supply(single) fL ft. '"'
❑Geothermal(Heating/Cooling Supply)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT'
FROM TO !s1:�7ERIAL EMPLACEMENT METHOD B.AMOUNT
FInjection
❑Wells= IOO,000GPD 0 ft- 20 ft. Bentonite Pour
Supply Well:
❑Recovery
ell: (t,charge ❑Groundwa[cr Rcmcdiation19.SAND/GRAVEL PACK if a 'cableFROM1i TU M1 �TF.RIALF.MPL.Aorage and Recovery ❑Salinity Barrier fL
ft.
❑Aquifer Test ❑Sto[Tnwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Tracer 20.DRILLING LOG(attach additional sheets if tie
❑Geothermal(Closed Loop) FROM TO DESCRIPTION(anlor,hardness,.zl;ck ne.Ein size,etc.
ft.
❑Gcotltcnnal(Hcating/Cooling Return) under#21 Remarks) f.) (explain
ft. ft.
Well tD# �-/� Sol
4-Date Well(s)Completed: ft. fL e��0:✓ rUri/ �i G
5a.Well Location:
ft. ft.
f
Faciliry�me Facility TDB(if applicable)
U/T fL
his i � skr ft.
Physical Ad ress ity,and Zip 21.REMARKS
t '
Parcel identification No.(PiN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certific on:
(if well field,one lat/long is sufficient)
VV �l
N
Si- r of r re W I ontractor Dat
6.Is(are)the well(s): ermanent or ❑Tempora �'
L,ry Bt si•Qnm,r this(ono.1 hereh,.cerrifi,h' the i ell(.$)was(mere)rnnstnicted in accordance a uh
/ A NCAC 02C.oioo or I?A A'CAC 02C.0200 Hrell Cnntuvcriar Standards and that a cnJn•
7.Is this a repair to an existing well: ❑Yes or 0 of this record has been prm•ided to them ell omier.
if rhis.is a repair.fill out known well constntction information and explain the nature nfihe 23.Site diagram or additional well details
repair under:.21 remarks.section or on the back e?l dris fnrnr.
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 1 GW-1 is needed. indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled: l
9.Total well depth below land surface:
(ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple uvells list all depths if different(ex(n AO@200'and 2(a1100)
40
24a. For All Wells: Original form to Division of Wafer Resources (DWR).
(fl-) Information Processing Unit,161,7 MSC,Raleigh,NC 27699-1617
10.Static water level below top of casing:
tfirater leiel is above casing,use"+'. 24b.For Injection Wells: Copy[o DWR,Underground Injection Control(lUC)
6 1/18 (in.) Program,1636 MSC.Raleigh,NC 27699-1636
11.Borehole diameter:
Air Rotary 24c.For Water Supply and O en-Loo Geothermal Return Wells:Copy to the
12.Well construction method: county environmental health department of the county where installed
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a Yield(-,Pm)
of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699 1611
__�Afr. Tabs •amount, 1 1/2 Lbs �
13b.Disinfection type:
l Quality-Division of Water Rcsou`rces
Revised 6-6-201 R
North Carolina Department of Environmenta
Form OW•I