GW1-2021-00032_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD.(GW-1) For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey '4•"^TERWNES
FROM TO DESCRIPTION
Well Contractor Name fL ft. -
3271-A fL tr ft•
NC Well Contractor Certification Number 15.OUTER CASING fo multi-cased,wells OR`LINER if a'Hcable
B & K Well Drilling Inc MOM TO, DIAMETER i THICKNESS MATERIAL
0 ft. 140 ft- 61/4 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eotliermalctICK-iES
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL fL in.
List all applicable well caratruction permits(i.e.UIC,County'.State. Variance.etc.)
ft, ft. in.
3.Well Use(check well use): lZ SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural
❑Municipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. i"•
❑Industrial/Commercial ❑Residential Water Supply(shared) 118.GROUT"' "
❑Welk>100.0—GPD FROM TO a1 ATERIAIJ EMPLACEMENT METHOD&AMOUNT
❑irri anon 0 ft. 20 ft- Bentonite Pour
Non-Water Supply Well:
❑Monitoring
❑Recovery ft. ft.
injection Well:
❑Aquifer Recharge ❑Groundwater Rcmcdiation 19SANSNGRAVEL PACK ifa cable
❑Salini Barrier FROM To MATERIAL EMPLACFMFNT METHOD
❑Aquifer Storage and Recovery ty ft fL
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control fL fL
20:DRILLING LOG'attae6 8ddition'al'-sheets`tf
❑Geothermal(Closed Loop) ❑Tracer DESCRIPTION(rnlor,hardness soiVroek e, rain s ze,etc.)
FROM ro
❑Gcothcnml(Heating/Cooling Return) ❑Otlicr(explain
/under
r##211 Remarks) O ft. D ft.40
4.Date Well(S)Completed:
W eII I D# /�/ / U fL tt. ra or 0 1— ��r
11 e. rL !d�ok. s27vv7 S� 1 S 0'i
5a.Well Location: /1 fL ft• s�j �Qei�
�I�Tnl,o !�//�Gli Ie_ �;Trt e V
Facility/Owner amc / Facility iDN(if applicable) ft. /J/�� �y�i
fL ft.
/`Cr a ft. fL
ci
Physical Addicss,City,and hip � /�O��
Sell GG 2irREMARKS
County
Parcel identification No.(PIN) DWR SECTION
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IN �UNVF
(if well field,one[at/long is sufficicny 22.Certification: �)
N W
St ature Certifie ell Contra or Date
6.Is(are)the well(s): ermanent or ❑Temporary
v signing this(onn.1 here
cerii rhat the well(sl µ'as(were)cnnstnrc�ted in accordance with
15,4 NCAC 02C.0100 or 1 SA NCAC 02C.0200 A'ell Coustrvetion Standards and that a cope
7.is this a repair to an existing well: ❑Yes or of this record has been provided to the well owner.
If this is a repair.fill out known well construction information and explain the nature of the
repair under��21 remark;.section or on the back of this form 23.Site diagram or additional well details:
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 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
y[/J (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi/ferent(example-3@200'and 2@100')
40 24a. For All Wells: Original form to Division of Water Resources (D
WR).
10.Static water level below top of casing: (ft•) information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
irirater level is above casing,use -"
6 1/18 24b.For lniection Wells:Copy!to DWR,Underground Injection Control(iUC)
11.Borehole diameter: (in) Program,1636 MSC,Raleigh,NC 27699-1636
Air Rotary 24c.For Water Supply and Open Loop Geothermal Return Wells:
(i.e.auger,rotary,cable,direct push,etc.) Copy to the
county environmental health department of the county where installed
12.Well construction method:
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin'>;over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program.1611 MSC,Raleigh,NC 27699-1611
lor. Tabs Amount: 1 1/2 Lbs
13b.Disinfection type: '-�
Revised 6-6-201 R
North Carolina Department of Environmental Quality-Division of Water Rcsour!cs
Form GW