GW1-2022-01853_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
FROM i TO DESCRIPTION
°' p �j
WdlContractor Name �^^' +t• +t•
3271-A fL «,
NC Well Contractor Certification Number
FEBr t 1 6 ���? 15.OUTER CASING for multi-eased'wells OR LINER'if a It cable
B & K Well Drilling Inc - - . �O�+ To UTAMETER I THICKNESS MATERIAL
1 - ,:..-:ft�Vri41 0 ft. ft- 6 1/4 I SDR-21 PVC
c.
Company Name rj'��l d6.INNER dSING OR TUBING( eothermal closed too
QFROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 1 ft. ft. in.
List all applicable well Con.structia)permits(i.e.LTC.Carmrv,state. Val-in .etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Municipal/Public ft. ft. in;
❑Agricultural
'JResidential Water ft Supply(single) . ft. i"•
❑Geothermal(Heating/Cooling Supply) P g
❑lndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO at ATER1Al- EMPLACE?+E\T METHOD&AMOUNT
®�ation ❑Wells>100,000 GPD O ft 20 ft
Bentoriite Pour
Non-Water Supply Well:
f
❑Monitoring
❑Recovery ft. i .
Injection Well: ft. 1
❑Aquifer Recharge ❑Groundwater Rcmcdiatiot' 19.SAND/GRAVELP K if it 'cable
❑Saline Barrier FROM TU MATERIAL EMPt,ACFMF.N'T T.IF.THOD
pAquifer Storage and Recovery ry ft. fL
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology
OSubsidence Control ft. ft.
Tracer 29.DRILLING LOG attach additional sheets=if.ne
m ❑
❑Geother al(Closed Loop) FROM Tp DESCRIPTION(color•hardness,soit/rock tNTe,grain size,etc-)
❑Geothermal(HcatinJCOOling Return) 00ther(explain under 421 Remarks) ft. ft. i
ft. ft'
4.Date Well(s)Completed: O( Well ID#
All, nt✓s
53.Well Location: ft. ft• dark11 i
—f f 1." + ft. ft
F--Faacffiliryi Ow'ncr'Namc Facility ID'-.'(if pplicable)
fL ft- I
ft. I ft.
Physical Ad�rless,City,and Zip21.REMARKS
(,iGII parcel Identification No.(PIV)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l22 Certification:
(if well field,one lat/long is sufficient) '
N
Stgnat e of rtifi ell Con. for
Date
6.Is(are)the well(s): ermanent or ❑Temporary
Br.rQnigG chic/ban.1 hereh c rr ,ihat the nell(s),vas(were)Cnnctnrcted in accordance with
15A NCAC 02C.O100 or 15 lsrCAC 02C.0200 Well Catstruction Standards and that r,corm
7.is this a repair to an existing well: ❑Yes or O O of this record has been provided to the,,veil owner.
if d:is-is a repair..ill out known well construcrlon infnnnatinn and explain the narure of the
repair,under 21 remarks secliat or on the back of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die 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 drilled: 24.SUBMITTAL INSTRUCTIONS
y +
9.Total well depth below land surface:
(ft.) Submit this GW-1 within 30 days of well completion per the following:
For nadtiple veils list all depths ifdilfereni(example-3Cd;20n'and 2@10n')
24a. For All Wells: Original form to Division of Water Resources (DWIRy
10.Static water level below top of casing:40 (ft-) Information Processing Unit, 1617 MSC,Raleigh.NC 27699-1617
l/:rater le,,el is above rasing.use"'
' (� 1/18 24b. For Injection Wells:Copy to D«`R,Underground Injection Control(IUC)
11.Borehole diameter: (I") Program,1636 MSC,Raleigh,NC 27699-1636
ll.Well construction method:
Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push•etc.) County environmental health department of the county where installed
—1 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
FOR WATER SUPPLY WELLS ONLY:
/1) Air Lift _ Permit Program-161 1 MSC.Raleigh,NC 27699-1 61 1
l 13a.Yield(gpm) V Method of test:
13b:Disinfection type:
Chlor. Tabs dmonnt: 1 1/2 Lbs
I
Form GW-1 North Carolina Department of Envircnmcntxl Quality-Division of Water Resources
Revised 6-6-2015
i