GW1-2022-01854_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1)
For Internal Use Only:
1.Well Contractor Information:
14.WATER 7AI"ES`:Joseph Bailey : ., i3l FROM TO DESCRIPTION
Well Contractor Name t\'w�.� 7
rt C
3271-At ft
FEBrEB16 " 2 -O
o13TE1t CASING` ar�,ila eaua
Ris11�i Ell
NC Well Contractor Certification Number -FROM TO DIAMETER ! THICKNESS MATERIAL
B 8t K Well Drilling Inc ;;,; �,4.:
u c�Urtt: 0 ft ' ft 6 1/4 in. SDR 21 PVC
try;� _
1 R G OR TURF4. , eethermal e&1oo
Company Name a� FROM TO DIAMETER ! THICKNESS MATERIAL
2.Well Construction Permit#:
ft '� ft tn.
List all applicable well corlSa-ttrtian permits— (e1 ounrv.State yarrance,etc.) fL ft. n.
t
3.Well Use(check well use): ;:1.7;SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Water Supply Well: ft ft in.
❑Agricultural ❑Municipal/Public
esidential Water Supply(single) ft. ft. 1D
❑Geothermal(Heating/Cooling Supply)
❑IndustriaUCornmercial ❑Residential Water Supply(shared) ig„GROUT
FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
❑1m, ation ❑weus>10o,000GPD 0 ft 20 ft Bentonite Pour
Non-Water Supply Well: ft fL
❑Monitoring ❑Recovery
ft ft.
Injection Well:
❑Groundwater Rcmcdiation
❑Aquifer Recharge EMPLACEMENT METHoo
79:SAN1)/GitAVEI'YAGIC'if-4 ""1ile
FROM TU MnTF.Rlnt
❑Aquifer Storage and Recovery ❑Salinity Barrier ft
ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Subsidence Control
�
❑Experimental Technology `
rain s(ze etc
2(1'i�RILLIIKG`YE7G attaeli add[6daal sheets d
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION hardness,
(color, WHIMek )
❑Geothermal(Heating/Cooling Rcrum) ❑Other(explain under#21 Remarks)
ft ft
Well ID#
a� ft ft. e °
4.Date Well(s)Completed:
ft ft �
Sa.Well Location: r ] ! ft. ft
/ ft. ft
Facility/Owner Namc acility 104(if applicable)
` I T ft ft.
ft ft
Physical Address,City,and Zip
1� I'h CO� Parcel Identification No.(FIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Cer cation:
(if well field,one tat/long is sufficient)
N W
$t lure o Certi ell Congas r
Date
6.Is(are)the well(s): rmanent or ❑Temporary /
B signing this form,!herekr ce rfy that the x'ell(s)was(were)constructed in accordance with
SA NCACO2C.0100, or 15A NCAC 02C.0200 Well Catstructio:Standards and that mcopr
7.Is this a repair to an existing well: ❑Yes oro of this record has been provided to the tiiell owner.
if this is a repair.fill out known well constntction information and explain the nature of the
repair under=21 remarks section or on the back of this form. 23.Site diagram or additional well details:
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
d surface:
drilled:
9.Total well depth below Ian
0�1 (ft.) Submit this GW-1 within 30 days of well completion per the following:
(a3100')
For nitdtiple},'ells list all depths if different(example-3@200'and 2
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfirater level is above casing,use-+" 24b.For Injection Wells:Copylto DWR,Underground Injection Control(TUC)
11.Borehole diameter:
6 1/18 (in,) Program,1636 MSC,Raleigh.NC 27699-1636
12.Well construction method:
Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
12.auger,rotary,cable,direct push.eta) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells produLina over 100,000 GPD Copy to DWR,CCPCUA
�br.
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699 1611
13a.Yield(gpm) Method of test:
bs Amount: 1 1/2 Lbs
13b.Disinfection type:
�f
Revised 6-6.201R
Form GW-I North Carolina Department of Environmental Quality-division of Watcr Resources