GW1-2021-00218_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD CGW-.1-1
For internal Use Only:
1.Well Contractor Information:
Joseph Bailey
14.WelTERZ01�� DESCRiPT1UN
FROM To
Via
Well Contractor Name
/AO
3271-A $ `DtAH�rER ORIIIRa ' �
fL
15.0UT-ER CASING for..mniti-cased'w THICKNESS MATERIaL
NC Well Contractor Certification Number FROM TO
B & K Well Drilling Inc 0 fL ft 6 1/4 in• SDR-21 PVC
n i6.iN VER CASII$G.ORTQBLNG eOthPrins2ZlO5Cfi IoO MATERIAL
Company Name ��� FROM TO DIANETERi THICKNESS
2.Well Construction Permit#:
fL ft
struction permits(i.e. IC,County.State.Variance,etc.) ffi ft.
List all applicable well con
77777777-77777777777777
3.Well Use(check well use): i .SCREEN
FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ff ft in
❑Agricultural ❑Munic' /Public
❑Geothermal(Heating/Cooling Supply) csldential Water Supply(single) fL
ft m
❑Residential Water Supply(shared) 1&GROUT EMPLACEME`T METHOD&AMOUNT
❑IndustrialICommercial FROM TO MATERIAL
❑Wells>100,000GPD 0 fL 20 fL Bentonite Pour
❑Irri ation
Non-Water Supply Well: ft. fL
❑Recovery
❑Monitoring ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Rcmediation i9 S�/GRAA, PACK:ifa "pole EMpLACFMFNT METHOD
FROM TO MATF.RIAI.
❑Aquifer Storage and Recovery
❑Salinity Bamer fL fL
❑Aquifer Test ❑Stotmwater Drainage fL
❑Subsidence Control
❑Experimental Technology 2i)DRILLING':LOG austhAadditionail sheets' m s em.l
❑Tracer FROM TO DESCRIPTIO?s(color,hardness,wil/ruck e,
❑Geothermal(Closed Loop) ft. '� j,
❑Geothermal(Heating/Cooling Rctum)
❑Other(explain under#21 Rctnarks) ft d
1�1/Jt�LP — fL fL rd4Al OB
��� ' Well ID# G�
4.Date Well(s)Completed: ft. ft.
S
4/
5a.Well Location:,
/'�/a 11/•I�i1 / �/ tl�! h ft. L t. ..rT� 1.:... ...
Facility ID4(if applicable) 1 z
Factliry/OwncrNamc r ft. fL
2 fL fLDE F-
P ysical A dress,City,and Zip G'- V /^ REMARKS' r+l
f�C4- Ir)n
Parcel identification No.(PIN) a Ku c l9i IG UNI
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification: //
(ifwcll field,one lat/long is sufficient)
W
N ature Certifie ell o ctor! a
6.Is(are)the well(s): rmanent or ❑Temporary_ ,,signing this form.1 herehi ert�that the well(s)was(were)constructed in accordance wirh
�f�// !SA NCAC 112C.UI40 or 15 NCAC 02C.0200 Well Cnnstrvction Srarsdardr and that a cop)'
7.Is this a repair to an existing well: ❑Yes or
° of th(.s record hoc hoer proy(ded to the well owner.
If this is a repair,fill out known well construction(nfnnnatimr and explain the nature 2f the 23.Site diagram or additional well details nfo
repair under:;21 remarks,cection or oil the back of this farm.
ction
You may use the back of this page You may]soeattach tadditionaonal l pages necessary'.
(add'See Over'in Remarks Box). y
$onsttu gopron W�1 nccdcd Closed-Loop Indic-ate TOTAthermal L tN'UMBER of wells e
24.SUBMITTAL INSTRUCTIONS
drilled: 2 0�1
(ft.) Submit this GW-1 within 30 days of well completion per the following:
9.Total well depth below land surface: 200 and 2(a3100) Dom)•
For nudtiple wells list all depths if different(exa,np(e-3@ 24a. For All Wells: original',form to Division of Water Resources
10.Static water level below top of casing:40 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
1f,caler level is abase casing,use"-" 24b.For Inje nd injection Control(IUC)
ction Wells:Copy to DWR,Undergrou
6 1/18 (in,) Program.1636 MSC.Raleigh.NC 27699-1636
11.Borehole diameter:
Air Rotary 24c•For Water Su iv and en-Loo Geothermal Return Wells:Copy to the
unty where installed
12.Well construction method. county environmental health department of the co
(i.e.auger,rotary,cable,direct push,etc.) Ito DWR,CCPCUA
=(gpm)
ELLS ONLY: 24d.For Water Wells roduen over 27690 611 Copy
Air Liftigh,NC 27699-1611Method of test:hlor. Tabs 1 -/2 Lbs
Amount--- f
Revised 6-6-201 R
North Carolina Department of Environmental Quality-Division of Water Rcs'rccs
Form GW-I