GW1-2022-01852_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD JQW-41 Only:
1.Well Contractor Information: 9d
A D ZON]ES
It V 14.WATER
Joseph Bailey FROM TO D nm ON*
Wcl I Contractor Name
FEB 16 7M
3271-A ft. fL
­'gurtil. .
:,.15.OUTER CASING' rmulti-cased
cation Number
ell Contractor Certifi, T DIAMETER
NC W ir y­'; FROM
ft. 11 ft- 61/4 in- ISDR-21 JPVC
B & K Well Drilling Inc 0
I&IN NL -1 U !L11 MATERIAL
ER:CASING OR LNM
T Company Name FROM TO DIAMETER
2.Well Construction Permit#: ft. in.
List all applicable well const-ctiOn Pe""t" UfC,County. tote.Variance,etc.) fL ft. in.
3.Well Use(check well use). fli.SCREEN %ids MATERIAL
FROM TO DIAMETER SLOT SIZE THICK?
Water Supply Well: OMunicipal/Public ft. in.
CAgriCUItUral
oRf-sl_d�ential Water Supply(single) rL fL in.
0Gcothermal(Heating/Cooling Supply
D Residential Water Supply(shared) I&GROUT
01ndustrialICOMmercial FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Water
A G
t r
0
S
C th e c s U u e
I p
u
p
a
gn I rm Supply
W
ra
Indu tnal/Com
e
e Well:
(Heating/Cooling For=Intemal Use Onl=y: =
77­77—����
mercial
0 Wells>100,000 GPD
0 Im, ati on ❑ 0 fL 20 IL Bentonite Pour
N 0
n-Water Supply Well: ft. IL
r. CRecovery
C3MOnitoring ft. ft.
Injection Well: ......
c 0 if c rg CGroundwatcr Rcmcdiation 19.SAND/G L:PACK lif cab -T M
Aquifer Recharge EMPLAUMEN rHOD
0 if Storage
Recovery
OSalinity Barrier FROM T MATERI I At,
0Aquifer Storage and Recovery OStormwater Drainage ft. ft.
C3 Aquifer Test OSubsidence Control fL ft.
oExperimentat Technology ddidd-al shert&if GL i*n -
oGeothermal(Closed Loop) ElTracer FROM TO �Nox(color.hardness,soiVrock e� in sues c-1
00dicr(explain I / of
_0G ti cffnal(Heating/Cooling Return) in under#21 Remarks) I ft.
Well ID#
ft.. fL dri
4.Date Well(s)Completed: 4'7 d-
ft. fL
5a.Well Location: ft.
Facili TT)4(ifap icable) 11 ft.
fL
Faciiiry/owncrNamc ft.
ft
ft
Physical Address,City,and Zip21.REMARKS
Pared identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N �W
Si aure Certified Well Corr or Date
6.1s(are)the welI(s): ;Pfr—manent or 0'remporary a,�wereL, nstrucredinaccordancetvith
,he e�11�
signing This form.I hereby certif,that the tiell(s)was(were)co
15A NCAC 02C.0100 or 15A NCAC'02C.0200 Rey Construction Standards and that a copy�
7.Is this a repair to an existing well: Ciyes or of this record has been provided to the well owner.
If this is a repair.fill our known well construction information and explain the nature of the
f f1iisform 23.Site diagram or additional well details:
repair under--21 remarks section or on the back a 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: i s of well completion per the following:
9.Total well depth below land surface; Submit this GW-I within 30 day
For multiple wells list all depths if differeni(example_-_T@20Wdnd 2@700') 24a. For All Wells: original I form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 (ft-) information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
if%vater level is above casing,use"+" 214b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
61/18 (in.) Program. 636 MSC.Raleigh.NC 27699-1636
11.Borehole diameter: Air Rotary 24c. I Geothermal Return Wells:Copy to the
12.Well construction method: county environmental health department 0­ecoun�
.auger,rotary.cable,direct push�etc.)
where installed
i 100,000161 GPD:Copy to DWR,CCPCUA
FOR WATER SUPPLY WELLS ONLY: 24d. MSC,Raleigh,NC T9--I
Air Lift Permit Program,1611
I ( Tim) Method of test:
[13a.Yield(gpm) 6pm
Chlor. Tabs 1 1/2 Lbs
f Amount:
13b.Disinfection type:
Revised 6-6-2018
North Carolina Department of Environmental Quality-Division of Water Res ources
Form GW-I