GW1-2021-05432_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(QW-1) For Internal Use Only:
1.Well Contractor Information: I
Joseph Bailey 14.WATMZONES
pz FROM TO DESCRIPTION
Well Contractor Name ft I I
* JyVe
3271-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING Nrnx2f
TO
FROM THIrKNFSS MATERIAL
B & K Well Drilling Inc Jrilcff"3%' iR Ssd()n 1
0 ft- 6 1/4 in- SDR-21 PVC
Company Name tt G, e
2.Well Construction Permit#: FROM DIAMETER THICKNESS MATERIAL
ft. ft. in.
List all applicable well co)jsnrcrion permits(i.e. un Corv,State.Variance.etc.)
3.Well Use(check well use): — ft. in. 17.SCREEN
Water Supply Well: FROM TO DIAMETER
SLOT SIZETHICKNESSMATERIAL
ClAgricultural DMunicipal/Public in
CGeothermal(Heating/Cooling Supply) pe,-&-ntal Water Supply(single) ft. in•
ClIndustrial/Commercial DResidential Water Supply(shared) I&GROUT
01nrigation o Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft Bentonite Pour
CMonitoring ElRecovery — ft
Injection Well: ft. ft.
CAquifcr Rcchargc OGroundwatcr Rcincdiation 19.SAND/GRAVELPACK' a l2h)
.1, EMPLACEMENT METHOD
Storage and Recovery ElSalinity Barrier FROM ft. TO ft. MATERIA.
0 Aquifer Test oStormwater Draina.-e
oExperimental Technology 0 Subsidence Control L
DRILLING']LOGIattitli.iddit to":sheetilj6FROM TO D dejjjj�):
OGeothermal(Closed Loop) OTracer
CRTP soiltrock e. in size,etc.
DGcothcrmal(Heating/Cooling Rctum) 00thcr(explain under#21 Remarks)
ft.
4.Date Well(s)Conmleted: VM2LWel1 ID# ft
fL ft.
52.W H L fL ft.
/_J
Facility/OwncrNamc Facility 1D,'(if applicable) ft.
ft
Physical Address,City.and Zip
-I_—r A C..// ea�_
County Parcel Identification No.(PrN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one[at/long is sufficient) 22.CertifIcation:
N w ���/
t re fC fled LOU ctor Date
6.ls(are)the well(s): 9,rXwwrfient or ElTemporary
.,signing r forin.I herebY c rtify at the well(s)was(were)constructed in accordance with
5A NCA C11C.0100 or 15A CA 02C.0200 91ell CnnsfmCdOn Standards and that a cop[7.Is this a repair to an existing well: OVes or of this record has been provi i the hell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under"21 remarks section or on the back ofthisform- 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 if necessary.
(add'See Over'in Remarks Box)-You may also attach additional pages ess; rY
construction.only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTION
9.Total well depth below land surface: .--(ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiffereni(example-3@200'and 2(a3100') 24a. For All Wells: Original f6rm to Division of Water Resources (DWR).
10.Static water level below top of casing:40 00 lrfor,Cation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfivater level is above casing.use'*+­ 24b.For injection Wells:Copy to DWR,Underground injection Control(IUC)
61/18 (in.) Raleigh,NC!27699-1636
11.Borehole diameter; Program,1636 MSC.
on method:Air Rotary 24c.For Water Su I and Open-Loop Geothermal Return 7e"i Copy to the
12.Well construction installed
county environmental health department of the county where in
(i.e.auger,rotary,cable,direct push,etc-)
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPO Copy to DWR,CCPCUA
13a.Yield Win) Method of test:Air Lift
Pen-nit Progr�m­l 611 MSC,Kalei g I i,
—Lq /1 1 1/2 Lbs
13b.Disinfection type: C of. Tabs s Amount:
I Revised 6-6-2018
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources