GW1-2022-01860_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GA-1)
For Internal Use Only:
1,Well Contractor Information:
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114.W�4TER:ZONES"
Joseph Bailey w : - I= FROM To DESCRiP7IO\
fL fL L
Well Contractor Name _ r1 qre
FEB 16 2t!2_ Soft. ft.
3271-A -::
=�st�OIlT£R`CASING':formtilt�ca5edw MATERIAL
NC Well Contractor Certification Number ,t,� �r..:�C�u 11;i ur111 piAM E'rER % THICKNESS
11ZA� �1 .' FROM TO
B & K Well Drilling Inc ft. fL 6 va '�' SDR-21 PVC
y
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Company Name y�> //��j� FROM ft TO DIAMETER THICKNESS MATERIAL
2-Well Construction Permit#:
List all applicable well carsmuction permits(ie.U C.Coemty,State.Vannnce,err.) fL fL in
3.Well Use(check well use): ',17:,SCl2EFN '' - - MATERIAL
FROM TO DIAMETER SLOT SIZE THICKNESS
Water Supply Well: fL ft. 1II
❑Agricultural ❑Municipal/Public
fL in
❑Geothermal(Heating/Cooling Supply) identml Water Supply(single) ft. w
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&tGRUUT.
FROM TO
MATERIAL EMPLACEMENT METHOD&AMOUNT
Cirri ation ❑weus>loo,000GPD 0 fa 20 ft. Bentonite Pour
Non-Water Supply Well: ft, ft.
❑Recovery
❑Monitoring fL tt.
Injection Weil: ,,:'.,:'
❑GroundwatcrRcmediation 19.SANDIGRAVEI`PAGK M Able
❑Aquifer Recharge ATERInL FMPLACEME\T METHOD
Barrier FROM it liny To
❑Aquifer Storage and Recovery ❑Sa ft ft
❑Aquifer Test ❑Stormwater Drainage
❑Subsidence Control
ft ft
❑Experimental Technology
❑Tracer 20z�RitSI111GIOG aaiaclisddthdaa7$tieetsd in sae,etc-)
❑Geothermal(Closed Loop) FROM To DESCRIPTION(color,hardness,smUrock
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under t/21 Remarks)
fL ft / O
�
4.Date Well(s)Completed: Well ID#_ fL fL
fL / ft.
52.Well Location: fL / ft 7
L /eP fL fL
Facility TDq(if applicable)
Facility/OwncrNamc ' f4 ft
Physical Address,City,and Zip 21aREMAILiFS '
Parcel Identification No.(PIN) Q
County (/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification-
(ifwcll field,one lat/long is sufficient)
N W
St re o erti red ell Con ctor
6.Is(are)the well(s): Ve.lment or ❑Temporary rigning this farm,lherebv rtify that the xeH(s1 was(were)constructed in accordance with
I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construct on Standards and that a cope
7.Is this a repair to an existing well: ❑Yes or of this record has been provided to the xell owner.
lfthis is a repair,fill out known well constmtction 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
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled:9.Total well depth below land surface: Z/
(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(unmple-3 a@200'and 2Q100')
40 24a. For All Wells: Original formto Division of Water Resources (DWR).
10.Static water level below top of casing:
(ft-) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
If water level is above casing,use—" 24b.For[niection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:
6 1/18 (in-) Program,1636 MSC,Raleigh,NC,27699-1636
Air Rotary 24c.For Water Supply and Open-Loop 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.)
24d.For Water Wells producint;over 100,000 GPD:Copy to DWR,CCPCUA
FOR WATER SUPPLY WELLS ONLY: Air Lift Permit Program,161 1 MSC,Raleigh,NC 27699 1611
13a.Yield(gpm) C Method of test:
1 1/2 Lbs
13b-Disinfection type:
hlor. Tabs AmaDnt:
Revised 6-6-2019
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources