GW1-2021-00036_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.wATER'ZONES
FROM TO DESCRIP UN
Well Contractor Name ft
3271-A it �! ft. -e
NC Well Contractor Certification Number 15.OUTER CASING fdr multi-cased wells OR LINER f a'ticahte
FROM TO DIAMETER
B & K Well Drilling Inc THICKNESS MATERIAL
p ft. /� ft- 61A SDR-21 PVC
Company Name ^�I 1 R.1TPVER CASING OR TUBING eotER,in.mePctoCKNI oo
�/ FROM TO DIAMETER, THICKNESS MATERIAL
2.Well Construction Permit#: fL ft i"
List all applicable well ronstruction permits(i.e.U1C,Coitnrv.Slate.Vannnee.etrJ
L fL in.
3.Well Use(check well use):
17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural
❑Munic' blic R. ft. in.
❑Geothermal(Heating/Cooling Supply)
sidential Water Supply(single) L R. i"•
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18:G OUT
❑We115>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑[rri ation p rt. 20 ft• Bentonite Pour
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Rcmcdiation 19 SANDIGRAYEL PACK fa ticable
FROM TO MATERIAL EMPLACEMENT METHOD
ClAquifer Storage and Recovery ❑Salinity Barrier i
(L fL
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20 1)RILLING`LOG.attactiDESCRnalION(color,
,hardn
FROM •fp DESCRIP ION(color,hardness so,Vrock type,grain size,etc.)
❑Gcothcnml(Hcating/Cooling Return) ❑Other(explain under#21 Reemmarks) ft. ft. sG�
I ,C ft. fL
4.Date Well(s)Completed: Or/a ` Well ID# LdEEJJJ Z✓
ft. ft.
5Ya. �ell
L/� Lion
: Lt ft
&ac.1-2
Facility/OwncrNamc
// f /^ �� L Q
1✓
ft. ft.
Physical Address City,and Zip '
C qI Zi:-REMARKS:',
aunty Parcel Identification No.(P! ) U��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: DWR SECTION
N W 6 r ATION MOM';"
Sig lure of ertified Well Contractor ate
6.ls(are)the well(s): ermanent or ❑Temporary
B,signing this firm.I hereby cert� [the u•ell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes Or 1 A NCAC 02C.0100 or I SA NCAC 02C.0200 Arel!Construction Standards and that a cop),
`��7%� of this record has been provided to the well owner.
If this is a repair,ill out known well con,str ctinn information and explain the nature of the
repair under'.21 remarks section or on the back of this Jnrm. 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 I GW-I is needed. Indicate TOTAL NUMBER of wells
24.SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: !7i v t (ft.) Submit this GW-1 within 30 days of well completion per the following:
For nudtiple wells list all depths ifdiereni(rxn nple-3ra3200'and 2@100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below'top of casing: (ft') Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
ff,raier level is above 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
(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 producing over 100,000 GP_D:Copy to DWR,CCPCUA
v Air Lift Pennit Program,161 l MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)� Method of test:
ChI41 Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
i
i Revised 6-6-201 R
North Carolina Department of Environmental Quality-Division of Water Rcsourl cs
Form GW-I

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