GW1-2021-00028_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(G-W-1
For Internal Use Only:
i.well contractor information:
14 W-ATER Zo S
Joseph Bailey FROM TO
ft.
Well Contractor Name 0
—7
It-
ft.
3271-A "el .01MINFR' A
15.0 - 'CASING mullil-cased
THICKNESS MATERIAL
NC well Contractor Certification Number FROM TO DIAMETER I
B & K Well Drilling Inc 0 ft. ft 61/4 ij SDR-21 PVC
TH
ICKNESS
ES
MATERIAL
Company Name FROM ft. TO ft. DIAMETER n.
2.Well Construction Permit#:
Li.qt all applicable well col'sn.u(.1ion pAgai;7Vanam�,etc.) � ft. ft. in.
3.Well Use(check well use): CREEN THIC 'NE!11 a ;7s
FROM TO DIAMETER ISLOTSIZE
MATERIAL
Water Supply Well: oMunicipal/Public ft. in.
DAgricultural ft. in.
(Heating/Cooling Supply) InResidential Water Supply(Single) -0,
-Tm THOD&A.NIOUNT
ClGeothermal(H (shared) Et, ETHO
0 Residential Water Supply ,I ..GROUT. EM LACE
CjIndu,trial/CornmerCial C]Wells>100,000 GPD FROM TO MAM-1­' Pour
0IM' ation 0 ft. 20 ft Bentonitib
Non-Water Supply Well: CIRecoverY ft. ft.
oMonitoring ft. ft.
Injection Well: ClGroundwater Rcnicdiation 19_SANDIGPAVFL PACK pie
EMPLACFMEN-f METHOD
0Aquifier Recharge FROM TO MATERIAL
ElSalinity Barrier ft.
0Aquifer Storage and Recovery C3Stormwater Drainage ft.
0Aquifer Test ft
ft
ElExperimental Technology El Subsidence Control Experimental
20. (colan hardness,soll/roll,qVc,grim size.dc.I
CITracer FROM TO DESCRI .
ON
C]Geothermai(Closed Loop) c3Othcr(explain under 921 Remarks)— ft. ft.
EIGcothenrial(Hcating/Cooling Return) Well ID# ft.
4.Date Well(s)Completed: ft. ft.
5a.Well Location: ft. ft-
Faciiity/0-ner Name Irm(if applicable) ft. fL
�acyJi
II
ft. ft.
Physical Ad s,cl and Zip NUV
le 021
County parcel Identification No.(PIN) All
yytN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees-
22.Certifi lion' G UVII I
(if well field,one lat/long is sufficient)
------------ N Si reotC ified ontractor Date B, igni)lgl ordance 6th
6.is(arc)the well(s):Ve'r' anent or 0'remporary the Was(were)canstnicied in acc
jcrinjhereln�cerfifY th th piey Construction Standards and that a copy
I' NCACO2C.oio0orl5AI C.0200
7.is this a repair to an existing well: 0yes or t5k� q this record has been provided to the well owner.
if this is a repair.fill out known well constri,crion information and explain the nature of the
; 23.Site diagram or additional well details:
repair under-:21 remork:5 section or on the back of thisforn,
o You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled:---------------- (ft*) Submit this GWA within 30 d!ays of well completion per the following:
9.Total well depth below land surface: e-3@�2 'and 2�@VIOO')
For multiple wells list'111 depths if differeni(example- 24a. For All Wells: Original form to Division of Water Resources (DV
40 (ft-) Information'Processing Unit,1617 MSC,Raleigh,NC 27699-1617
10.Static water level below top of casing: Underground injection Control(IUC)
"e casing.
Infection Wells:Copy to DWR,
!(neater'level is above ing.use 24b.For 1�n
61/18 27699-1636
(in.) Program,1636 MSC.Raleigh�NC
11.Borehole diameter* Wells:Copy to the
E Loi Geothermal Return
Air Rotary 24c.For Water Su Iv and 1 11:1 1 1' ' --.:. —
12.Well construction method: county environmental health department of the couni�_)Xere installed
(i.e.auger,rotary,cable,direct push,etc)
Copy to DWR,CCPCUA
24d.For Water &r�,d�'d,-_-
P -1611
FOR WATER SUPPLY WELLS ONLY: Permit Program,1611 MSC,Raleigh,NC 27699
Air Lift
I ( p In Method of test:
13a.Yield(gpnl)_LV4W_
or. Tabs . 1 1/2 Lbs
Di f Amount,
13b.Disinfection type:---
Revised 6-6-1-01
North Carolina Department of Environmental Quality-Division of Water Resource,
Form GW-I