GW1-2022-09847_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD (GW-1) For Internal use only:
1"Well Contractor Information:
e e Alfr d K i slin Sr
Well Contractor Name
-FRO I TO ~-1D7:-SC:RrPiTOV /ti:
2670-A © r
fL - ft. i IQ -f ,
NC Well Contractor Cerrification Number f$e
D
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:. ;V;<r`.1:BiZ:.�' N�...tis�a¢ltriiase'r. tls: giia_ '= ?;•r:.:: >,:r ':�:;
B & K Well Drilling i n c I FROM TO DIA-METER THICKNESS I MATERLLL
0 ft- I.Sj ft- 61/4 la SDR-21 JPVC
Company Name
i
j :
2.Well Construction Permit 0- �/ ' ` 3 3 FROM 1 7.O DIAMETER THICKNESS M11AlERIAL
List all applicable wcl(carurruc6on permiu .c.WC.Cawrrv.State.b-ariancc,e1c•.) f[. i fL
in-
3.Well Use(check well use): ft_ ft, in.
Water Supply Well: _ IAM..... _.. ....:. .. ..
FRONT TO DIAMETER SLOT SIZE THICKNIS$ MATERIAL
❑Agricultural ❑Municipal/Public ft. I rL in.
❑Geothermal(HeatinJCooling Supply) l<dential Water Supply(single) ft in.
❑lndusnial/ConmTercial ❑Residential Water Supply(shared)
❑irrigation ❑Wells>100,000 GPD FROM TO X%TEFdAL L E*IPLACEXEN7 MLrHOD&A IUU*1T
Nutt-Water Supply well: 0 fL 20 fL Bentonite Pour
❑Monitoring ❑R=ovcry fr. ft.
Injection Well
• fL ft.
❑AquiferRecharge ❑Grou dwaterRamadTatlon
..: ..... .....,.:....: ::,_:-.:;.>.,-,.:.�:.�:;.::.:.;.:;:..�.�::•;::..:,,...:..::•:••::••;•s.,�.,::::
>S19:&41\BIGt AV—L S£ cabLc}•:_:::;:;;<:?.;.r;::::r:•
❑Agmfer Storage and Recovery ❑Salinity Barrier FROAl TO MATERIAL. EMPI-k Hemet METHOD
0-Aquifer Test ❑Stormwater Dminaee ft. ft.
❑Experimental Technology ❑Subsidence Control rL fir.
❑Geothermal(Closed Loop) ❑Tracer `:��#Rpf3'GifiTGr� aiiscti'a�iieiiriafe«e�at�):::%?%:::i:::;:s:<>�?rz�;;�:::;�::^•
❑Geothermal(HeatinJCoolinspReturn) ❑Oche'(explain under#21 Remarks) f�S ft �, ft" y�j f
FROM TO DESCRIPTION(whir hardns illna k —' me.eta)
s A
4"Date Well(s)CompletW: / I`� 2�WellTD# V fc. fL l��
ft. fL
Sa"Well Location:
.; taci
Fa�c /✓il+ity�/(hsmerName Facilitvml(ifapplicable; ft.
, fr. fe
/ t^.�Ct Y` 7r'd 7` - 1 fL a . +' S as )
Physical.4ddras,City,and Zip
ft. ft- OCT T .
?-2i`RE7( 1i
R
�Tsl Z o�• !�O b
1
In;L;�?s;i3n Pry^�r�R7 ilrc'sl
Couaty Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,om lat/long is sufficient) 22_Cettifi tiu
N W % �zr'rJJ/
6.Ware)the well(s): IJPermanent or ❑Temporarc S:rnat .ofCenined Well Connactor Date
Br signing thin lbnrt,l hnreht•rerrifr rhm •e+:rllrsl+vas(ivern)<onsrrurred in arrordmx•e r:idr
7.Is this a repair to an existing well: 0-Yes or -nNo 1 s-I NCaC 02C.0100 or 15.4 KCAC 02C.0200 Tf eACotctrrucr.-on Standards and rhai a corn
1/'rhrs is a repair fi/lnra knohr will c•anrtncation infonaatinn and erplair.the narurr of the of this rrcnrd has baenprmided ro the+--ell os ner-
repair rardar#21 rem n*s section or on the back of rhfs form.
- 23"Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells Navin-the same You may use the back of this page to provide additional well construction info
construction.only 1 GW-1 is needed. Indicate TOTAL NUMBER-ofwells (add'See Oved in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 1 / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (ft.)
For multiple+trtfs list all depilcs if df ferenr(Gtample-3(a+_00'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top ofeasing:40 24a. For All Wells: Original forth to Division of Water Resources (DIA'R),
tf+niter level is above casing.use-+•- (ft.) ,,formation Processing Unit,1617 MSC"Raleigh.NIC 27699-1617
11.Borehole diameter"6 1/8 (in) 24b.For Injection Wells:Copy to DWR-Underground Injection Control(IUC)
Pro�am,1636 MSC,Raleigh,NC 27699-1636
Air Rota
12.Well construction cable. method: 24c"For Water Supply and Opeo-Loop Geothermal Return Wells:Copy to the
[i.e.auger,rotary"cable"direct push,etc.)
county emironmental health depatvnenr of the county There in,talled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DN'R,CCPCUA
13a.Yield(gpm) C2 Q Method of test:Air Lift Permit Pro_mrn.1611 MSC,Raleigh.NC 27699-161 t
13b"Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina D yarrmcnt of En%ironmcnral Quality-Division of Warcr Resources Revised 6-6-20[A