GW1-2021-00038_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1
For internal Use Only:
1•Well Contractor Information:
777�7
14:.W 4TER ZUPIES nEscn ON"
Joseph Bailey FROM To
^ ft f4' >/«
Wdl Contractor Name
ft fit �
3271-A
15.OUTERCASING.for. ID—cased:welis OR-LINER
NC Well Contractor Certification Number FROM TO DIAMETER I. THICKNESS MATERIAL
B & K Well Drilling Inc o fit ° fit 6 1/4 '9 SDR-21 PVC
r4SING OR'LUBBZG eotherinal tloseH loo
(0�/ /' "�HNTER THICKNESS MATERIAL
Company Name � /I,/�I "SOH TO DIAMETER
2.Well Construction Permit#:
V fL ft in.
licable well constructiat ermit n
s(i.e.U/C.County.State.Variance.etc J ft ft in
List all app P
3.Well Use(check well use): 17 SCREEN THICKNESS MATERIAL
.FROM TO DIAMETER SLOTSIZE
Water Supply Well: ft ft. in.
OMunici al/Public -
❑Agricultural sldenual Water Supply(single) ft ft in.
(Heating/Cooling Supply) ❑Residential Water supply(shared)
❑IndustriaU FROM TO
Commercial pp y B.GROvr MATERIAL EMPLACE MENT METHOD&AMOUNT
❑Wells>I00,000 GPD p ft. 20 It. Bentonite Pour
Olri ation
Non-Water Supply Well: ft fit
❑Recovery`'
❑Monitoring fit fit.
injection Well:
❑Aquifer Recharge ❑Groundwater Rcmcdiation 19 SAND/GPkVEL PACK-Ma ATF:RIAI.gbte EMPLACFME�T ntETHOD
FROM TO
M
❑Aquifer Storage and Recovery
❑Salinity Barrier fit ft
El Aquifer Test OS[ormwater Drainage tt.
fit
OSubsidence Control
❑Experimental Technology DRILLINGLOG atta h4dditionalsheetsif; in size etc.)
❑Geothermal(Closed Loop)
❑Tracer FROM
TO DESCR[P (rnlar,hardness,sotUrock e
❑Other(explain under#2] Remarks) fit fit
DGcothcnnal(licating/CoolingRctum) , f!ft �h�� ��
i) ft
� Well ID# V
4.Date Well(s)Completed: ft fit
5a.Well Location: j�J' fit ft 'G�y
r i��l �Q f G �lO ft. ft
Faci ty TT)4(if appiicablc)
Facility/OwnerNamc _ ft fit CC
ft 2 r�
Physical dress,Ci ,and Zip ✓� / fry ZI REMARKS" N O V
Parcel Tdcntufication No.(P!N) t��p� C/�-r p�
ounty UVV SLIT I ION
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification: IP:FOROTIQN PR SIN UV-
(if well field,one lat/long is sufficient)
W
N Oat
lure of rtified Contract
6.is(are)the well(s): eormanent or ❑Temporary g ,signing this form.l herehy ce ' that the lmll(s)was(were)con Standatnictedrds
in accordance redthawith
I A NCAC 02C.0100 or 15A AC 02C.0200 well Cnnsttuctiar Smndards and that a cop'
7.Is this a repair out
known
existing well:
❑Yes or `f!a 22fVvvo of!his record has been provided to the well owner.
if this is a repair,fill out known well on the back
fih&narinn ahtd explain the nature of the 23.Site diagram or additional well details:
repair under��21 remarks sectiat or on the back of this form es if necessary.
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
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled:
(ft.) Submit this GW-1 within 30 days of well completion per the following:
9.Total well depth below land surface:
Fa'multiple wells list all depths ifdii ferent(tunmplO 0 'a d 2(a�100') 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
nd Injection Control(TUC)
lfureter level is above casing,use"* 24b.For Ini ietion Wells:Copy to DWR,Undergrou
6 1/18 (in-) Program,1636 MSC,Raleigh,NC 27699-1636
11.Borehole diameter: p to the
Air Rotary 24c.For Water Su 1 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.) P to DWR,CCPCUA
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over I00 OIKI GPD:Copy
i5 Method of test:Air Lift Permit Program,161 1 MSC,Raleigh,NC 27699-161 I
/
13a.Yield(gpm) 1 1/2 Lbs
136.Disinfection type:Chlor. Tabs Amount:�----
North Carolina T)cpartment of Environmental Quality-Division of Water Res urcct Revised 6-6-201 R
Form GW-1