GW1-2021-00242_Well Construction - GW1_20211213

WELL,CONSTRUCTION RECORD(GW-11 For interns)Use Only:
1.Well contractor Information:
Joseph Bailey 1 -WATERzo>r�
FROM
TO DESCRIPTION .
Wel I Contractor Name _ L I'�7 tt• �i•y-!� I�yr��
3271-A 'JJ fL fL zg!,,� 1�.,
NC Well Contractor Certification Number is.OUTER CASING for multi=cased wells OR LI iP;a lica.TERLAL
FROM TO DIAMETER THICKNESS . MA
B & K Well Drilling Inc 01 ft. ft• I6 1/4 SDR-21 Pvc
Company Name J ,�,L (•y 16.INNER C45ING OR TUBING(geothermal closed - -
/ /JY�I/1 �`7� FROM TO DIA?•IETER THICKNESS MATERIAL
2.Well Construction Permit#: ` / rt. ft • in.
Lirr all npplirahle well construction permit.a(i.e.U1C.Cnunn, Late.Vnrinnce,ec.l fG ft.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS n1ATERIAL
Water Supply Well: nicipal/Public in.
❑Agricultural
❑Mu ft ft'
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. f[.
❑IndustriaUCotnmercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri stion ❑Wells> 100.000GPD 0 ft 20 ft. Bentonite POUT
Non-Water Supply Well: t[.
❑Monitoring ❑Recovery
Injection Well: tL
❑Aquifer Recharge ❑Groundwater Remcdialion 19,SANDIGR4VEl PACK ffli ¢able
❑Aquifer Storaac and Recovery ❑Salinity Barrier
FROM TO M:1TF.RIAL F.MPL.ACRMENT METHOD
ft. fL
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if )
❑Geothenm ❑Tracer al(Closed Loop) FROM TO DES IPTION(e jar,hardness,soiUroek h e gain size.etc.)
o ❑Other(cx lain under r21 Rcmarks) ft 0 ft. �7
❑Geothermal(Hcating/Coolina Rctum) P y ` CJ
4.Date Well(s)Completed: /� Well ID# 1
� ft. fL
�y
h /Y�
5 a.Well Location: '� r ft, ft.
l./.
Facility/Owner Name 62 ft. rL
Facilit iD'A(ifap !cable) Q
P ysiea�l Address,City,and Zip ® 21.REM- ARKS l
( er41 i _
.d
Parcel identification No.(PiN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certif Lion: /
(if w'cII field,one lat/long is sufficient)
N
re f rtifie Contras r�
Oat/
6.Is(are)the well(s): ermanent or ❑Temporan -
t? .signing rhis farm.l hereby re t or the%,e!!(s)was(e•en)<:anstrnrred m accordance kith
nYes Or �16 1 A NCAC 02C.fii0 or hA AC 02C.0200 Ntell Canshvcrion Standards and that a cone'
7.is this a repair to an existing well: of rhis retard has been prnrtded io the.,ell owner.
if this is a repair.fill out known well constntnion iryormario!and explain the nature of the 23.Site diagram or additional well details•
repair under-.21 remarks section or a!the hack nhhis form.
You may use the back of this page to provide additional well construction info
S.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-1 is needed. indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled:
9.Tgtal well depth below land surface:
(ft.) Submit this GW-1 within 30 days of well completion per the following:
For nndtiple u'eits list all depth ifdiffe, (uxo nple-?Ca,.00'and 2(a;100')
40 24a. For .All Wells: Original ;form to Division
of Water Rcsourccs'(UWR).
10.Static water level below top of casing: _ (ft') Information Processing unit,1617 MSC,Raleigh,NC 27699-1617
if neater 1eve1 is ub—e casing.use"+' 24b.For in'ettion Wells:Copy to DWR,Underground injection Control (lU(-)
6 1/18 _(in.) Program.1636 MSC.Raleigh•NC 27699-1636
11.Borehole diameter: -
Air Rotary 24c.For Water Su Iv and O en-Loo Geothermal Return Wells:Copy to the:
12.Well construction method: county environmental health department of the county where installed
(i.e.auger•rotary',cable,direct push,etc.)
FOj2 WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over I00,000 GPD:Copy to DWR;CCPCII:\
Air Lift Pen,it Program,1 '!I MSC•Raleigh.NC 2 7 699-161 1
132.Yield(gpm) Cato Method of test:
Chlor. Tabs AmoDmt: 1 112 Lbs —
13G.Disinfection type:.
i
i; North Carolina Department of Env
ironmenLal Quality-nicimon of Water Resources
Revised 6-6-'_01 R
Form GW-I
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