GW1-2021-00033_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey FROM ER ZONES
FROM TO DESCRIPTION
L tt. •r�
Well Contractor Name �--
3271-A ft. ft.
NC WclfContractor Certification Number 15.OUTER CASING for multicased we]ls OR LINER(ita heabte
FROM TO DIA>tETER THICKNESS MATERIAL
B & K Well Drilling Inc 0 ft. I ft- 6 1/4 'I" SDR-21 JPVC
Company Name /,� j// 16-INVERC.4IN GORTIIB LNG eo[hermaletosedloo MATERIAL
U / D FROM TO DIAMETER THICKNESS
2.Well Construction Permit#: L ft ft• ; in.
List all aeahle well ronstruction erntits(i.e.UIC.Cntmrn.State.6'arianre.e:c.l
PPl t� P a(L -ft. I in.
3.Well Use(check well use): 17.SCREEN
W21I. FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply
f[. in.
❑Agricultural DMunicipal/Public
fi. i
I Sid ft. '"
❑Geotlietmal(Heating/Cooling Supply) ential Water Supply(Single) L
0lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri st;on ❑wells%100,000 GPD 0 f- 20 ft. Bentonite Pour
Non-Water Supply Well: ft l I
❑Monitoring
ORecovery ft'
Injection Well: ft. ft.
❑AquiferRechargc ❑GroundwaterRcmcdiatioo 19.SAND/GR4VELPACK ifa ble
❑Salntl Barrier FROM TO NIATF.RIAt. EMPI.ACF.MF.NT 111_ D
❑Aquifer Storage and Recovery ty fL ft.❑Aquifer Test ❑Stormwater Drainage
ft.
❑Experimental Technology OSubsidence Control
f[.
20.DRILLING LOG attach additional sheets if
❑Tracer ne
❑Geothermal(Closed Loop) FROM TO D&SCRIPTION Icolor,hardness,soft/rock 92e, roin situ,etE.l '
DGcothcnnal(Hcating/Cooling Rctum) ❑Other(explain under#21 Rcmarks) I R. i fL Sir
ft. ft.
�Q
4.Date Well(s)Completed: / % I Well ID#
Sa.Well Locati n: ft.
=�ti�r ski�� Q,cm- c�� 5 n ft. ft. -
1 Facility IT)t(ifapplicable)
Facility/Owncr Namc ft ft.
Physical A dress,Ciry..and Zip 21.REMARKS
. � , U
Parcel Identification No.(PTN)
County NOV
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certi titian:
(if well field,one lat/long is suff eient) - DWR SEC /
N W' INFORARATIN PR
ate.
r attire o enifi' Well Contr'tor
6.Is(are)the well(s): ermanent or ❑Temporan'
1,signing this loon.1 here r rrifiI that the was Mere)rnn,rmaved in ae'rordmrre with
�y�..-- hA NCAC 02C.n1nn or 1 NCAC n2C.n2(1n 1t`c//Crntstruction Standards and that a cunt'
7.Is this a repair to an existing well: DYes or (c nJ this record has been provided to the"/I owner.
/Jthi.c is a repair.jill out known well c nnrtntctinn infnnnminn and explain the nature n/the
repomunder::21 remarks section or att the back of this.16"'. 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).iYou may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled: ; /) I
per the following:
9.Total well depth below land surface:
L� (ft') Submit this GW'-I within 30 days of well completion
For eudtiple trells list all depths if different(example-3(30 2pn'and 2(a,1001
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below tap of casing:40 (fit.) Information Processing Unit,1617 MSC.Raleigh,NC 27699-1617
l f trgter level is ubol•e 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
12.auger,rotary.cable,direct push.etc.) county environmental health department of the county where rnsta e
FOR WATER SUPPLY WELLS ONLY: 24d. Copy[o DWR,CCPCUA
For Water Wells producing over 100,000 GPD:
13ar'Yield(gpm) Chlor. T T Method of test:
Air Lift Pennit Program,16l 1 MSC.Raleigh,NC 27699-161 1
abs 1 1/2 Lbs
13b't Disinfection type: Amount:
I
i
Revised 6-6-201 R
North Carolina Department of Environmental Quality-Division of Water Rcsos rcc
Form(iW-I
f
7: