GW1-2021-04316_Well Construction - GW1_20210404

WELL CON'STRUCTiON RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey FROM TO i)EscRIP l
ION
W cl I Contractor Name ft ft 144 G 4fii ;Zdne
3271-A ZQZ °f
AN� X ft. ft
NC Well Contractor Certification Number U11tt
COG@c1Ct� tS..OUTERCASING fortdailh c9sedwel15 ()R;LINER ita 'Ticable
B & K Well Drilling Inc �1)10fr 3tloln P rtl�ll FROM TO DIAMETER THICKNESS MATERLAL
MNS S�� p ft. Mto tt 6 1/4 in• SDR-21 PVC
Company Name ]6;ITINEROASINGORf3BING e4
I/VI{/•� 'FROM TO DIAMETER THICKNESS, MATERIAL
2.Well Construction Permit#: fL fc
Litt all applicable well consnvctio+permits(Le. IC,Co+mrv.State,rrariance,etc.) to
ft. ft in.
3.Well Use(check well use):
i7:SCF:EEN `
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft fL in.
❑Geothermal(Heating/Cooling Supply) rdential Water Supply(Single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
-
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20 ft Bentonite Pour
❑Monitoring ❑Recovery ft ft.
injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Rcmediation Iq...SANp/ VEL FACIC ifa cable❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MA RIA IF.M PI.ACF:MF,hT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control R. fL
r-
20'DRILLINC'.AG attar addinoitallaheetstd ae
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DE.SC TION(color,hardness,so+Urock 'n Am.etc.)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) fL fe e _15do
4.Date Well(s)Completed: / ,g Well ID# Af �Lo ft. 0 ft. Oip
ft. 0 ft 0� -4
5a.Well Location: y�
l� Aw S p fL d ft J 0
facility iD# ifapplicable)
ft
F ift
Facility/Owner Name Y (
t.
7 - r f,4.,� � � ft ft
�ir�lr S�U�// _
Physica ,Ciry, t.
and Zip ,
4o
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certif ation•
N W l
Si azure Cert+ Vellontractor D6.ls(are)the well(s): ermanent or ❑Temporaryr signingthis form.1cent that the nell(.$)was(were)constructed in accordance nilh
7.Is this a repair to an existing well: ❑Yes or DPW — 15.4 NCAC 02C.0100 or 15A NCAC 02C.02oo Well Construction Standards and that a cops•
If this is a repair,fill out known well constmcction information and explain the nature 0./'the of this record has been provided to the well owner.
repair under 21 remarks section or on the hack of lhts forme 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 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: ��/� (ft-) Submit this GW-1 within 30 days of well completion per the following:
For nndliple wells list all depths Ili d(�ereni(example-3Q200'and 2(a3100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijrraler level is above casing,ys•e
6 1/18 24b. For injection Wells:Copy to DWR,Underground injection Control(iUC)
11.Borehole diameter: (in•) Program,1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: Air Rotary
24c For Water SDApIV 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Om)�s�,�_ Method of test:
Air Lift Pennit Program,1611 MSC,Raleigh,NC 27699-161 1
136.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Revised(r6-201 R
Farm GW-I North Carolina Department of Environmental Quality-Division of water Raources�