GW1-2021-05430_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14JiWATER'7ANES
FROM Well Contractor Name ROM TO DESCRIPTION
3271-A 1 ,�+�'�� No ft i 9t� ft Inej !A�4 e—
NC Well Contractor Certification Number IVA (t ft
Cry\C\� OUTER GASTNG for inuln-cased wells OR I INER tFg hcable:,. .
B & K Well Drilling Inc ��(OLF\fin FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 1 7 ft 6 1/4 SDR 21 JPVC
Company Name 16.=WNERt`i1SING ORTQBING- euiherinial:doseda
t �
AP 33�N
2-Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C.County,State.Variance.etc.) ft ft im
3.Well Use(check well use): N ft ft in.
17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.,
❑Geothermal(Heating/Cooling Supply) rdential Water Supply(single) fL ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 111 GROUT`
L
❑[m anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite Pour
❑Monitoring ❑Recovery ft. ft
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation
79.SANDYGRAVEL PACK if:a bTe
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F.MPLACEMF-NT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.:DRILId1kGliOG:attacli additianal`sheetsiLIIe
FROM TO DESCRIPTION(color,hardness,sorUrock n size,etc.)
❑Gcothcnnal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) ft � fe L Sal
4.Date Well(s)Completed: Well iD# ft fc Je/� . di
5a.Well Loca' n: rt ft ello"I !a. a,
Faciliry/Owner amc Facility iDh(ifapplic bIc) �' 'v�t ( / `
�v
Physical Address,City,and Zip
21:;REMARILS°
�.Lrr ,wit f� I/W 9 -96) 0?
County Parecl identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certify 'on: /y
N W /C1
6.ls(are)the well(s): ermanent or ❑Temporary re fCefdWR, o etor Da
�� Bn igning this form.I hereby certify thaiwl,
ells)%-as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V#10 1 NCAC 01C.0/00 or 15A NCAC 00 Well Construction Standards and that a copy
If this is a repair.fill out known well construction information and explain the nature of the of this record has been provided to the m-ell owner.
repair under'+'11 remarks section or an the back of rhis fnrra
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only i GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �O (ft') Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths ifdierenl(example-3@200 and 1@100')
24a. For All Wells: Original form to Division of Water Resources (DR),
10.Static water level below top of casing:40 (ft,) WInformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter 6 1/18 (in) 24b.For injection Wells:Copy to DWR,Underground Injection Control (IUC)
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
r
f
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingfover 100,000 GPD:Copy to DWR,CCPCUA
Air Lift Pennit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /(/ Method of test:
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources' Revised 6-6-201 R