GW1-2021-08134_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-11
For Internal Use Only:
1.Well Contractor Information:
i4:WATER'ZUNES DEscxmno
Joseph Bailey FROM TO ! n
tuft f r fL jljl� I
Well Contractor Name fL
3271-A d a..Ucab
S.OLiTERGASiP1G°€or.miilti{ssed'wells.OR THICKNESS1 MATERt4L
NC Well Contractor Certification Number
FROM TO DIAMETER
ft t.
16 IN vI R C ING ORTIIBIicIG eodt DR-21 PVC
B & K Well Drilling Inc
1 f g 1/4
ermal s3osed-ltw ..MATERIALF. .
J TO DIAMETER ' THICKNESS
Company Name FROM I"
.� ft ft
2.Well Construction Permit#: ft to
List all applicable well consnut•riat permits .e.U/C,County.Scare.Vannnce,etc) ft
........
3•Well Use(check well use): 37;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: fL ft,
❑Muni pal/Public
❑Agricultural ft
❑Geothermal(Heating/ Supply
esidential Water Supply(single) ft
❑Residential Water Supply(shared) j&GROU'1 pt pTEAIAL EMPLACEM E>•T METHOD&AMOUNT
❑Industrial/Commercial FROM TO
❑Wells> 100,000GPD 0 ft 20 ft Bentonit2 Pour
❑Irri ation
Non-Water Supply Well: ft ft
❑Recovery
❑Monitoring ft ft.
Injection Well: bie
❑Groundwater Rcinediation .1-9SSAN1)/fsRAVEL PACK:if.'a EMPLACFMFNT METHOD
❑Aquifer Recharge FROM To MnTEAInL
❑Salinity Barrier ft. ft
❑Aquifer Storage and Recovery ❑Stormwater Drainage
❑Aquifer Test fL tt
❑Subsidence Control ;n siza cm.)
❑Experimental Technology Zp:.Dg}3 LIr1G;T OG attach additional'sheeea ff
❑Geothermal(Closed Loop)
❑TracerpM TO DESCRIPTION ketor,hardn sorUrock 4
❑Otter(explain under 421 Remarks) ;� ft ft
❑Gcothcnnal(HcatinglCoolin Cmm) I ft - tL td%7 01
4.Date W ell(s)Comp
leted. Well ID# fL ft 1 �IoG✓
ft ft a l l
52.Well Location: ft. Li
16orf Co Facility ID#(if applicable)
acility/OwncrName ft ft
L ft. fL
Physical Address,City,and Zip Zl:'gEMkRRS'r
4-44 o,T �d Parcel identification NO.(PIN)
County TION PROCESSING UNIT
22.Ce Ication: INFORI(RA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —�
(if well field,one[at/long is sufficient)
W
N ate
ature of ertife ell Contra or
6.Is(are)the weil(s): ermanent or ❑Temporary' ,,signing this form.1 hereby cer that the uell(s)%us(were)co,Standacredrds
in accordance with
__-// A NCAC 02C.0100 0r 1 SA N AC 02C.0200 Well CO"strucrion Standards and that a cop'
7.Is this a repair to an existing well: ❑Yes or
`JprO njrhia record has been provided to the%.ell owner.
this is a repair.fill out knoxm Fell cOnstnrcti0n information and explain the nature of the
if 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
repair under:-21 remarks sectiar 0r on the back 0jrhis j0rm- - also attach
8.For Geoprobe/D additional pages if necessary.
PT or Closed-Loop Geothermal Wells having the same
(add'See Over'in Remarks Box).You may
construction,only I GW-I is necdcd. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled:
L�� (ft-) Submit this GW-1 within 30 days of well completion per the following:
9.Total well depth below land surface: urccs (DWR)-
) Rcso
For multiple wells list all depths if different(example-3(a)100and 2(a3100 24a. For All Wells: Original form to Division o 2 Water
17
10.Static water level below top of casing:40 (ft-) Information Processing Unit,1617 MSC,Raleigh,
lfiraterleyel is above casing,use"+ 24b.For infection Wells:Copy to DWR,Underground Injection Control(IUC)
6 1/18 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
1.Boreholediameter: to the
Air Rotary 24c.For Water Su lv and en-Loo Geothermal Return Wells:Copy
12.Well construction method: county environmental health department of the county where installed
(i.e.auger,rotary.cable,direct push,etc.) to DWR,CCPCUA
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells rodticina over 100 000 GPD:Copy
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm Method of test:) 1 1/2 LbS
lor. Tabs Amount:
13b.Disinfection type:�---
Revised 6-6-201 R
North Carolina Department of Environmental Quality-Division of Water Resource,
Form GW-I