GW1-2022-00138_Well Construction - GW1_20221219

"'Pnnt Forlr
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey ra:wnTERzoNEs .
F
Well Contractor Name v S aim FROM '1'O DESCRIP•rION
1 11 iti. :...c�s•..e e ft. ft. 4G
3271-A s �/ are2a�e
NC Well Contractor Certification Number DEC I q 2022 ft.
]5.OUTER CASING'for multi-cased':wells OR LINERVifa"lies
B&K Well Drilling Inc FROM TO DIAMETER' THICKNESS MATERIAL
P7O<;3Gv: llriiY ft. t ft. I in.
,iTT /{�� 61/2 SDR 21 PVC
Company Name r t fhr�r v'�rc,7
y 16t INNEWCASING ORTUBING i`ebthe mal-closed-Ioo
2.Well Construction Permit#•�( /yl t �/ 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 []Municipal/Public
Geothermal(Heating/Cooling Supply) Idential Water Supply(single) ft. ft.
IndustriaUCommercial Residential Water Supply(shared) 18=GROUT-" t:' '`t, , . :.•{
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 1 fL D e- ar
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery [g+3�'�,Salini Barrier FROM
SAND/GRAVEL PACK`MATERIAL
„
q g ry @;.,1' tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control It. ft.
Geothermal(Closed Loop) OTracer 20 ][IRILLING,:LOG attach addiddoil sl'e d'lf uecessa"` r
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM To DESCRIP'ION(color,hardness,soil/rock type, rain size,ete.)
ft. ft.
4.Date Well(s)Completed: l Well ID# ft. ft.
5a.Well Location: I J ft. ft. /a� • 0 r
13� n Ca6h lr HOIIQ 4/ e✓Lu- Jl ri' e D�/ ft. (� fL l �'d L✓ S''i
Facility/Owner Nam act try ID#(if applicable) ft. fL yn 4 oL 5 .5`•i'
d dc/
Physical Address,City,
W and Zip ) ('� ft. ft LY
. d C
Rka CCJ�
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.Certification:
N W
6.Is(are)the well(s)oPermanent or Temporary Sig ofC tificd*ell Contractor Datc
By.-igning this form,I herebv certify that the well(v)was(were)c•onsu•ucted in accordance
7.Is this a repair to an existing well: [3Yes or `o w +I5A NCAC 02C.0100 or 15,4 NCAC,01C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature oflhe copy of this record has been provided to the well owner.
repair under 921 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: � + (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Ca 200'and 1 a l00') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniecton Wells: In addition n to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
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
/E�LLLSS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J 6#/ Method of test: 24c.For Water Supply&Iniectio I Wells: In addition to sending the form to
the address(es) above, also submit gone copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1I2 i bs completion of well construction to the county health department of the county
where constructed.
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Form GW-1 Notch Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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