GW1-2022-00112_Well Construction - GW1_20221219

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
r �
Joseph.Bailey 44 WATERzoNES','
Well Contractor Name ; .{� p' 9 FROM TO DESCRIPTION
Alm 3271-A �v IY. /le_
ft. ft.
NC Well Contractor Certification Number DEC ICI v: 2l'n
ZZ i.:IS.OUTERICASING.formulii cased:wells L NER if.a lleAble `'.•: , . ..:,:.,
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
y v rr t v 0 ft. f ft. 6 1/2 tn' SDR 21 PVC
Company Name I �',7iiT4�+IDD f i
.i r�pq 16:�INNEii'CASING:OR=TUBING. eotheYmal.closed=iuo _ �a ,,.�:�..;. t �1:
2.Well Construction Permit#• J�! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U7C,County,State,!Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Wa SS ter Supply Well: FROM TO DIAMETER SLOTSIZE THICKNE MATERIAL
Agricultural 13Municipal/Public % in.
Geothermal(Heating/Cooling Supply) srdential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) ;18.GR011Px•.
Irrigation FROM TO MATERIAL EMPLACEM NT METHOD&AMOUNT
Non-Water Supply Well: ft. ft , `�
Monitoring ORecovery
Injection Well:
ft. ft
Aquifer Recharge OGroundwater Remediation
g'.&IOM/GRAVEL PAQC if
Aquifer Storage and Recovery 13SalinitY Barrier
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [39tormwaterDrainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .::20'DRILLiNG:LOG attncli'idditionsl,ibeetiiLneceis'
FROM TO DESC IPTION(ca r,hardness,saillrock e, rain size,etc.
Geothermal(Heatin Coolin II Return) Other(explain under#21 Remarks) ft. ft. t�4 ,SOJ
4.Date Well(s)Completed: Well ID# /S ft- 0 ft' L."ni 30,11
52.Well Location: Gl LL .�� Q ft. /n ft. ��y/ QI t
d 1Ske h4ve-7�S�S D fL iOv ft
Facility/Owner Name racilityID#(if applicable) ft.
f% 5-OFT 6d
Physical AHress,City,%Ad Zip ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cerl ation:
N W J,`
6.Is(are)the well(s)oPermanent or Temporary S' nature Ccrtific ell Co r Dat
y signing this form,I here rtijy that the,vellls)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or P'1Vo with 15.4 NCAC 01C.0100 or 15A NCAC 01C.0100 iYell Construction Standards and that a
Iflhis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record hay been provided to the well owner.
repair under#11 remarks section or on the back of this form.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( G (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@106') construction to the following:
10.Static water level below to of 40
p casin g: (ft.) Division of Water'Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
Air Rota above,also submit one copy of this form within 30 days of completion of well
Rotary
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
/ /n � i
13a.Yield(gpm) 1 U(rml Method of test: 17 i 24c.For Water Sunaly&Iniection Wells: In addition to sending the form to
the address(es) above, also Istibmit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1i2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Reisources Revised 2-22-2016