GW1-2022-01861_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
' �+ r.� 'l+f:WA'#�It Z'ZONES
Joseph Bailey FttoM TO DESCRIM70K
Well Contractor Name I-EB 16 2n22 L / fL
3271-A ln� , i&,OUTEWCASING forisultt-case&R
t)rttl fc
'��3.tv;1 .• ells:ORT:Ii!TER tf'a 'ficR11
NC Well Contractor Certification Number �R,rl�i DIAMETER THICKNESS MATERIAL
rJ• FROM TO
B & K Well Drilling Inc 0 ft. fL 61 i" SDR-21 PVC
�f �yy� �
Company Name �//�Q�'_ V J 1fi iD!I?VER C9SING:ORITTBIAM f eot)Serma7 etICKNES
FROM TO DIAMETER THICKNESS
MATERIAL
2.Well Construction Permit#: fL ft in.
List all applicable well construction permits(t.e.UIC.County.State.Variance,etc.) fL in.
fL
3.Well Use(check well use):
I1 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMunicipal/Public ft L f
❑Agricultural
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft
in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 1g uR6UT
O Wells>lOQ 000 GPD FROM TO M&TERIAI EMPLACEMENT METHOD&AMOUNT
Cirri ation 0 fL 20 fL Bentonite Pour
Non-Water Supply Well:
OMonitoring
ORecovery fL ft
injection Well: fL fL
❑Aquifer Recharge
❑Groundwater Rcmcdiation
19:SrYNDlGRAVEL.PAGIZ;t
OSalini Barrier FROM TO MATERIAL F.MPLACFME.,T METHOD
❑Aquifer Storage and Recovery h' fL fL
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer FROM- IL3ING'EE3G aitiieliDESCR17PTIsYeet4 or
FROM TO DESCRIP1701 lot,ha ess.soilltvek "n svt,ere.)
OGcothermal(Heating/CoolingE�Reeturn) ❑Odrer(explain under#21 Remarks) fL v ft. C Q
4.Date Well(s)Completed: /,71 Well iD# L6� fL fL U/
e& fL fL
Sa.Well Location: J fL fL
y :C e/kakllf _5f �e5� % fL
-b facility iDK(if applicable)
Facility/OwnerNam'c� ��,�
1 J( 1�i '�`�— t',t�1,j�J(��T ft fL
Physical Address,City,and Zip 103006 a��ga. ;
21: tl hfAI2RS.i
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tainting is sufficient) 22.Certification'
N W
Sign a of nified onoactor Date
6.is(are)the well(s): ermanent or OTemporary
B signing thLc form,1 hereby certify r t the ivell(s)was(were)constructed in accordance with
an existing well: ❑Yes or � I NCAC 02C.0100 or ISA NCAC OlC.0100 Well Construction Standards and that a co
7.Is this a repair to p if this is a repair.fill out known well construction information and explain the nature of the of record bar been provided to the ar[/owner.
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 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
9.Total well depth below land surface: U (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple tre/ls list all depths if different(example-3 200'and 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DR).
10.Static water level below top of casing:40 W
(ft) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f ivater level is above casing,use
6 1/18 24b.For Injection Wells:Copyjto DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Su y 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Q Method of test: ,
13b.Disinfection type: d6f or. Tabs Amount: 1 1/2 Lbs
V
Forth GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 R