GW1-2022-09774_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use only:
1.Well Contractor Information:
Alfred iesl'n Sr
K r
FROM TO DESCRIPTION
Well Contractor Nartx ft. ft. Q
09 If We1-�
2670-A r
03-fL p S'ft-
NC Well Contractor Certification Number
=(3F$EER:E33_NG"` ecm '.isisi: ': $iRE•R' .;.... .,,:;
B & K Well Drilling inc FROM TO D1AXETER THICKNESS MATERLAL
0 fr 6 1/4 i° SDR-21 PVC
Company Name :i..?;.>:>;.::::>
/`/
2.Well Construction Permit#:A! ?79 2 11,67 FROM 'I'O DIA11E-rER THICKNESS i I MATERIAL
Litt all applicable well corutrucGon perrnirs fi.e.WC.C'onurrv.Starr.t%ar.'anCt'.etc.) it. j fL
in.
3.Well Use(check well use): ,
ft- ft. i°-
SE321�ii>i�Er:%:i`.' :'.:...:•.::.�i:1� ::::ii:�ci::iii':.:�'Es:ia:>•:::C°�i ijE �'#d:`":2'•.;::i iii:.>'�is::.
Water Supply Well: OM T _.. ... .
FRO DIAMETER SLOT SIZE THIC.KNFSS MATEFt1Al
0•Agricultural ❑MunicipaUPublic rt. fL in.
❑Geothermal(HeatinsziCooling Supply) BKesrdential Water Supply(singlej ft- fL in.
❑industrial/Conmtercial ❑Residential Water Supply(shared)
:Git�Ji3F:>::':>:i:•<i:%ii::r: :>>::'>:>:3>:3<i3: .<;>::'::' :' :''>..>:;>>
❑irrigation ❑Wells>100,000 GPD FROM I To NULTERIAL EMPLACEMENT MLrHOD&.01OUNr
Nun-Water Supply Well: 0 fL 20 fL Bentonite Pour
❑N•Ionitoring ❑R«ovcry fL ft.
Injection Well
fL ft.
a
r Recharge
❑A ui fe Rbaz_ OGroundwater Remadiation
>:<I9c:&4n`BsGizav�Ga'' �f::,,.:,.;. kY`•:<:;<>:: '>:'>z<: ::;<:>} �%><��>:<�>:;��; i:<%'.>;<E`•z��>.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROPI I TO I MATERIAL F.MPLSCEMENT METHOD
❑AquifesTest OStormwaterDrainage fL I ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer z >SRLiNGiI 'atiackaiiouaEflecc3ari22>:>%z;':<:<:'v>:<>:<::E#:::;z; ,;'
FROI.1 TO DESCRIPTION(color.hardn soBhock ortvr size,etel
❑Geothermal(Heatin?1Coolins Return) ❑Other(explain under=21 Remarks) It. ft. lr,-12 �r
4.Date WeU(S)Completed^ '/ aWell ID# tt. 30 ft.
5a-Well Location: (9 ft. fL
L L C
Facility/OnrtrNamt / Facilityll# fapplfcablel fr. fL
fr. i ft.
Physical Address,Ciry,and Zip K• fL R
fs
County Pagel Identification No.(PIN)
ILI
F :u T of6xsa
5b.Latitude and longitude in des /s ees/minuteseconds or decimal degrees: D Djtj1 e
(ifv.•cll field,one Iaf110na is sufficicntl 22-Certification; /+
r
6.Ware)the wetl(s): InPermanent or ❑Temporary __.atw-e-A'mined WpIrcontnictor Date /
. 3rsr,nin�tks tbr7n.lherei+?-rertfjr rirar rite+:rtlrsl+ens(r� eJ<»nsrrurved in accordance n.irh
7.Is this a repair to an existing well: GY'es or �No !sa:vC:+C 0 C.olnr,or ls.4 n'c,IC n2C.o20n Wefi rcatrnctivn Standards and that a cum
!j rhis is a repair,Ill our kno+,r.well<»nrtr a rion inrar».arion and ernlarr,the narurr of the ofthis record has horn prorided to the+:r11 o—er,
repair Hader+21 rema7cr section or on the back ofrinsform.
23-Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
NIJ
construction.only 1 GW-I is needed. Indicate TOTAL MBER�of weils (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
domed' 24.SUBMITCAL INSTRUCTiONS
9.Total Kell depth below land surface: C3 OS (ft)ForSubmit this GW-1 within 30 days of well completion per the following:
multiple wells li r all depilo•if rlfffe7•enr(erample-3(at_00'and @100�
10.Static water level below top of casing:40 24a. For All Wells: Orieinal form to Division of Water Resources (Dw'R),
!r outer(errl is uhare casing use"+"
(ft.) Information g Processin Unit,1617 MSC.Raleigh.NC 27699-1617
11.Borehole diameter:6 1/8 ( ) 24b.For Injection Wells:Copy to DWR-Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Air Rota
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(;.e.auger,rotary.cable,direct posh etc.) county entironmental health department of the county Where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DH'R,CCPCUA
n 13a.Yield(gpm) Method of test:
Air Lift Pcrmit Program,1611 MSC,Ralaigh.NC27699-1611
1�
13b.Disinfection type: Chlor. Tabs Amount 1 1/2 Lbs
Form GW-1 North Carolina D Tanmcnt of Enrironmcntal Quality-Division of Water Rcsourccs Rcvisod 6-F-201 A