GW1-2021-00083_Well Construction - GW1_20211109

For internal Use Only:
WELL CONSTRUCTION RECORD(GW-11
u contractor information:
1.We 4.
------ om TO
Joseph Baileyim
% ft. C...tl
well Contractor Nainc
3271-A ItCASIN tri'm wem 0 T,H ICKNE SS MATERIAL
DIAMETER
NC Well Contractor Certification Number FROM. TO I O ft .7 ft. 61/4 in.' SDR-21 PVC
B & K Well Drilling Inc
G THIC M RI AL
Company Name FROM ft. TO ft. DIAMETERin.
2.Well Construction Permit#' UIC.(_oun�v,3111— ft. in.
n-uCtron Pe),Mils(i.e. ft.
List all applicable well calls
use): 17 DIAMETER S
.SCREEN TSIZE TtilCKNESS MATERIAL
3,Well Use(check well FROM TO
1: ft. ft. in.
Water Supply We
0munici blic ft.
DAgricultural Water Supply(Single) It.
&Rirsidential
(Heating/Cooling Supply) W OCeothermal r Supply shared) CEMEN,ME
oResidential Water 19.GROUTM:T E METHOD&AMOUNT
01nduStriallCOMInereial FROM ro
pour
C]WeIlS>100,000 GPD 0 it- 20 ft. Bentonite
E]Irci ation ft.
Non-Water Supply Well: ORecovery ft
c2Monitoring Z,.
P
Injection Well'. [3GrOundwatcr Remcdiation To MATERIAL
cAquifor Recharge oSalinity Barrier FROM
ft. ft.
0 Aquifer Storage and Recovery []Stormwater Drainage ft. ft.
0AquiferTest
0subsidence Control 3f
I.. ILLIN6 ifdditiorial�sheets hardness, OiVmck mn size,,tL,
C3Experimental Technology 2&DRILLINiG DES
OTracer FROM TO
OGeothermal(Closed LOOP) ClOther(explain under#21 Remarks) ft. ft.
0GcOthcrmal LHcating/Cooling Return — ft ft.
Completed: Well ID# Lea ft. N ft.
4.Date Well(s)Con' ft. ft.
5a.Well Location:
ft. ft.
Facility TD#(if icabic)
Fact ity/Ow ncrNa m c
. r
ft ft
�" ft�yand ZipPhcalAdd,.s,
R&AA_a2_ p.tired Identification No-(PIN) 20 1
County s/minutes/seconds or decimal degrees: -22 Certification: DVVR SECTION
5b.Latitude and longitude in degree
(if well field,one latilong is sufficient) INFORMATION P
W ate
N Sig orary B1, gning1h C i Contra"CE ihat the vvellis)was(were)constructed in accordance wit
,
V65-`anent 11 oTempLiform f hereby cer C 02C.000 Well Consil'uCtion Standards and that a COPY
6.Is(are)the well I' NCACO2C.oio0orl5A1V
-7.is this a repair to an existing well. Oyes or !Z�:nature()frhe )f1his record has been proi,idedw the ueli owmer
Ifthis is a repair.fill out known well construction information ai 23-Site diagram or additional well details- tion info
or on the back 1)fthisform page to provide additional well construe
repair under:'21 remarks sectionyou may use the back of this: may also attach additional pages if necessary
e/DPT or closed-Loop Geothermal Wells having the same (add'See over'in Remarks BO)0-You
9.For Geoprob 1 is needed. Indicate TOTAL NUMBER of wells INSTRUCTIONS
construction,only 1 GW_ 24.SUBMITTAL _ UC TIONS
drilled: —(ft.) Submit this GW-1 within 30 days of well completion per the following:
9.Total well depth below land sull-.Ce-—__,R L,�� — f Water Resources (DWR)-
,is,.11 depth,ifdifferen, 3@200'and 29(u") 24a. For All WelIS4 origidal form to Division 0
For multiple wells Processing �1617 MSC,Raleigh�NC 27699-1617
10.static water level below top of casing:40 (fo Information,g Unit,:Onj COP),to DWR,Underground injection Control(IUC)
24b.E ��:COP
Ifivater level is above casing,use` Program,1636 MSC,Raleigh,NC 27699-1636
1.Borehole diameter:6 IM8 v art 3 Geothermal Return Wells:COPY to the
Air Rotary 24c.1:or Water So if the county where installed
1-2.Well construction method: county environmental health'department
CCpCUA
(i.c,auger,rotary, able,direct push.etc.) loo 000 GPD:Copy to DWR,
Water wells roducin'2Ye�99
"In J!!,��
24d* Wells
rOduR,f,_'igh,NC276 -1611
t Program.Permit MIIISMSCM
FOR WATER SUPPLY WELLS ONLY:
Air Lift
13a.Yield(gym) Method of test:
35el o r. Tabs Amount* 1 1/2 LbS
13b.Disinfection type: Revised 6-6-201 R
North Carolina Department of Environmental Quality-Division Of Water Resource,%
Form GW-I