GW1-2022-00025_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
3271-A ft- ft. I /rIs/ j�r�t r, ore
ft. ft. I li
NC Well Contractor Certification Number
15.OUTER:CASING ftir'iaulti-cased wells OR'LINER ifa 'lica6le
B&K Well Drilling Inc FROM TO I DIAMETER THICKNESS MATERIAL
Company Name ft / p1 / ft' I 6 1/2 In' SDR-21 PVC
c�(� p �� 16ANNERCASINIG;ORTUBING eothertnalclosed-lou
2.Well Construction Permit#: !/drJ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.UIC County•State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN -. ... . :.... .. =..,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Mf<idetial Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply shared
PP Y(shared) 18;GROII'1' ;.;••
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. 6C/T
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge c •m � -Lti ft. ft.
q �Groundwatcr Rcm�dl�afion '.19,SAND/GRAVEL-PACK(if a cable
Aquifer Storage and Recovery nSalinity Barrier D-f' 't 1 q zon FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage `� ft. ft.
Experimental Technology E3Subsiden% grltrpl:i �P�fDvx;,�'i'nC' 2 ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLINGI:OG attiichadditi6iWsheetsifceces ..
Geothermal(Heating/Cooling Return) Other(explain/u FROM TO tinder#21 Remarks) ft. ft. DESCRIPTION(color,hardness.soiltruck a in size,eta)
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4.Date Well(s)Completed: Well ID# LOr 11 ft. YO ft. rdV41 sad
5a.Well Location: qO ft- 0 ft- el/Q✓ I rJ I Sa
Rfywoi ,--Ahk J/O4leY v JJy A11V Of q"C"
re rd V4 J Facility/Owner Name Facility ID#(ifapplicable) ft -
t• rLIN/�'J O( 6v
�� ,JJeriN0116 r• 0 X,,407TU/�, N� aY/ oft 13 fL d OG
Physical Address,City,and Zip /� 30 ft. ft- �
ye sa C�,_ n a,4 U' 2.REMARKS
a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
N W /h
6.Is(are)the well(s)oPermanent or OTemporary Signa rc of C ificd 1Vcll Contract r Datc /
By.s ping this fnrm•1 hereby'cerd • nt the uell(s)was(were)constructed in accordance
7.Is this a repair to an exisdng well: 13Yes or xit! 15A NCAC 02C.0100 or'15.4 NCAC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,fill out known well construction information and explain the nature gf1he copy of this record has heen provided to the well owner.
repair under#21 remarks section or on the back of this form. i,
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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
1' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•
) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:.'
10.Static water level below to of casing:40 I
P g: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6 1/8 !
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above,also submit one copy!of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sk r'ice Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: r G/f 24c.For Water Supply&1�niection Wells:'In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
t 1/z Lbs
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016