GW1-2021-04687_Well Construction - GW1_20210521

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information: ' f,V
Joseph Bailey , '� �� 14 WAfERJNES ;3
FROM I TO �DESCRIP ION
Well Contractor Name 202ti ft ft �.�
3271-A 15.ouTER"rakslrlG'friunw cased;
ft ft
1Yt1
NC Well Contractor Certification Number p �1 J{�Cc gl l 6 1/4 wells 13RL R'ff le '
B & K Well Drilling Inc tv.[O�r 'i S r r$t r��n FR017 TO DIAMETER THICKNESS MATERIAL
0 ft. ft. in, SDR-21 PVC
Company Name
]�"INKER.CA$[1rtG R T4JBING eotltermal e1ased 100
% �A-1 2.Well Construction Permit#• FROM To DIAMETER THICKNESS MATERIAL
• ft. ft mLitt a1!apphrnhle well rnncovctiar permits(i.e. I . a'.State.Unriance,etc.)
ft ft 1n•
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft it. in.
❑Geothermal(Heating/Cooling Supply) esidential Water.Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMO
❑irri anon UNT
Non-Water Supply Well: 0 ft. 20 tt Bentonite Pour
❑Monitoring ❑Recovery ft. ft.
injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19 sSAND/GRtI'V�L FACKI rf a hcalde ;:' _� t :�,_ ,.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. FMPLACEMFNr METHOD
❑Stormwater Drainageft ft
❑Aquifer Test
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
f1aDRA,I.TNis�OG:aftac"tr�additfoial%�`heetsat �,` ,
FROM 1 TO DESCR TiON(color,hardness,soillrock e,°rain size,etc.) l
❑Geothermal(Heating/Cooling Return) OOthcr(explain under#21 Remarks) ft ft Q�
4.Date Well(s)Completed: � Well 1D#
ZQT b ft. ii fL
I ft !? ft. j1 fc
5a.Well Location:
(�/ L/ ft. fc �✓
Ja^ ft ft
a�al/i�{/ry'/p� ncr�eN�Jafm'c ,},�.�F'acLilit�1�✓(ifapp/li�cablc) �i
Gh
L3ILJ- +.I'---� �001 Y✓� /'J f� IV L ft ft
Lc.-re,
Physical Address,City,and Zip A
to
County
Y Parccl identification No.(PTN) e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Cer [cation:
f
N W
- e o Certifie ell Contras r! Da
6.Is(are)the well(s): ermanent or ❑Temporary
p signing this form.I hereby certt that the trel!(s)>+ns(were)constructed in aecor.Im¢e with
7.Is this a repair to an existing well: ❑Yes or 5A NCAC 02C.0100 or 15A NCAC 01C.0200 well Construction Standards and that a cop),
If rhis it a repair,fill out known well construction information and explain the nature of the of this record has been provided to the"It owner.
repair under'?I remarkr section or on the hack 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 l 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: Q�!/✓ (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Ca3200'and 2Ca3100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (fL) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
I(untev level is above casing,use"+•'
6.1/18 24b.For Injection Wells: Copyfto DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh.NC 27699-1636
Air Rotary Copy 12.Well construction method: 24c.For Water Supp1Y and Open-Loop Geothermal Return Wells:Co co 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 produciriq over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /S�40M Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
Tabs
13b.Disinfection type: C tor. Amount: 1 1/2 Lbs
4
i
Rcvisc 16 6-201 R
Form GW-I
North Carolina Department of Environmental Quality-Division of Watcr Resources
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