GW1-2021-04317_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Onty:
1.Well Contractor Information:
Joseph Bailey �,� la.WATEWZONES
� > 10 FRUM TO DESCRIPTION
Well Contractor Name � d f"lft. �ft le /ice L��pCj
3271-A AP� X � 2021 iL fL ;/
NC Well Contractor Certification Number a + ISO OUTER CASING f`r m6ldie ed we11s OR LINER f i ecible
B & K Well Drilling Inc abOull oc
essJ%no Ut11� FROM TO DIAMETER THICKNESS MATERIAL
loafr
!i"• SDR-21 PVC
Company Name J 0�_
I6 INNER CASING ORY CUBING eothermalelosed-l2.Well Construction Permit# L11"�ll' t3aFROM TO DIAMETER THICKNESS MATERIAL
' ft. ft. ':�in.
List all applicable well cmishvction permits(i.e.VIC.Counm State,Variance,etc'.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munic'pal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) /IA fL it to
❑industrial/Commercial ❑Residential Water Supply(shared) '18.•GROUT
❑irri atiOn ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 I'L Bentonite Pour
❑Monitoring ❑Recovery fL ft.
Injection Well: 4 f3. FL
❑AquiferRccharge ❑GroundwaterRcmcdiation .19;SAND/GRAVEL PACK(if a j ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. F.MPLACEM F,NT hfF.THOD
❑Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control f3, ft.
❑Geothermal(Closed Loop) ❑Tracer 20.:D DRILLING`LOG ittick addtHoual'sheetsif n8cess
FROM TO DESCRIPTION(color,hardness soil/rock e, rain size,etc.)
❑Gcothennal(Hcating/Cooling Return) ❑Other(explain under#2'1/Remarks) tL fL
4.Date Well(s)Completed: .Z. Well ID# T fL ft. I '
it. it. X-// r � t
Sa.Well L odor:
ft. ft. f,/
Xlay Awe-
facility ID# ifa licablc fL fL
aciliry/OwncrNamc Y ( PP ) Q `/
1 q�G61J��� G �. 54/ d �l�• ft. f�
Physical Address,City,and Zip
Oka _O. �/ /f / 21i<REMARKS:.t
County C Parccl identification No.(PTN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one[at/long is sufficient) 22.Certification:
N �l -
Signa f e ied el ontractor D e
6.Is(are)the well(s): rmanent or ❑Temporary
Br. going this form.I hereby cent that to nell(,e)was(were)constnicted in accordance with
7.Is this a repair to an existing well: ❑Yes or Pro I SA NCAC 02C.0100 or I jA NCAC C.0200 Well Construction Standards and that a cony
If this is a repair,full out known well construction information and explain the nature of the of/his record has been provided to the well owner.
repair under:;21 remarks.cection or on the back of this form. 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -(ft.) Submit this GW-1 within 30 days of well completion per the following:
For maltiple wells list all depths ffdi/ferent(example-3(P200'and 2@I00')
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
/f vater level is above casing,use"+"
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 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,t:CPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
or. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised(i 6-2011 k
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