GW1-2022-00140_Well Construction - GW1_20221219

I
WELL COsNSTRUCTION RECORD(GW-1) For lntemal Use Only:
1.Well Contractor Information:
Alfred •esl'n Sr
FROM TO DE.SCRiP1!ON'
Well Contractor Name t. ft. � f I L ,Q d G7 11A
2670-A r �!
NC Well Contractor Certification Number IJb,'6 fL �O ft. /�I (✓
::>1�54)FIBERifu�N uedcssed$e1is:; ltQE31{ ::::: :....•.;;.:;:; ::,.::;?::i:;:;::
B & K Well Drilling Inc FROhI TO D1A_METER I THICKNESS I NIATERL•11.
0 ft. I,r v7 ft. 6 1/4 I in SDR-21 1PVC
Company Name
�Tl � i eetlierID�'das�d�':.:;..,i:z:'°.3,:'s'�'•s:f:;:C<'�; :<i?'[%i`;:`.:
r� %:FRONT C Fi.C31� BAIL �
2.Well Construction Permit 9:_S FItOPI I'O ll1AMErER THICKNESS 117ATEH1:1L
Livr all applicable well construction permits fix.U1C.Comte r..State.Pa'ance.etc.) ft. I fL in..
ft.
3.Well Use(check well use):
a>::>'':•.;;<`:<<-':>c < zzi?<;::.<:4;;:
Water Supply Well: _... ._. ... _ .... .
FRONT TO � DIAMETER $LOT SIZE Ni THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. (L
❑Geothermal(HeatinsiCooling Supply) 41<idetttial Water Supply(single)
❑lndustriaKonunercial ❑Residential Water Supply(shared)
shared)
❑Irrigation ❑Wells>100,000 GPD FROM To I bL>TERIAL E41PLA2EvIE\7 METHOD&.(A(UU^rI
Nutt-Water Supply Well: 0 20 fr- Bentonite Pour
❑1\4onitoring ❑Rcc:ovcy It. ft.
Injection Well: _
❑Aquifer Recharge ❑Grouudwater Remediation
:339:'&41�`�'1GiZ::1V�iP4f1,4�t� le}•:i:%:iii::'.:.:<::�:;c%:::<:.,�c:>:;:::2'::.:::;:;�`::;;:::?:;:::�?i:::�::::
❑Aquifer Storage and Recovery ❑Salinity Barrier FRONT - TO MATFRIAI, F,MPL>CENIENT METHOD'
L'�Aquifer Test ❑Storalwater Drainage
It. ft. i
❑Experimental Technology ❑Subsidence Control rL ft.
❑Geothermal(Closed Loop) ❑Tracer :Zff':BRI£I3N£i0C<i:ttvtli'alierislis9eeessa. :::
FR t1f TO DESCRtPTtoN'(color.hardness wilfrock• Yrain sae.etc.l•.
❑Geothermal(HeatinJCoolke Return) ❑Other(explain under#21 Remarks) ft. ft. v9 rJ
4_Date Well(s)Completed // �well ID#
r y�
Sa_Well
rLocation: � ft. fL
87YLs 3
Facility/OwmerName Facilit. (if applicable, ft_ fL
sloa—
Physical Address,City.and Zip fry ft
23'#RE11�itR1t;
7J Lr K
11r,7ur ,t1d,n 'r. ..3r E,ri'.
County . Parcel Identification No.(PIN) �••ry•ry
Vuryl 4(1 rl�r�
5b.Latitude and longitude in deb ees/miaates/seconds or decimal degrees:
(if well field,one latrlong is su cicnt) -2.Certific tipn: n
. N W
6.is(are)thewell(s): C1Permanent or ❑Temporary S_.at ofCertitiedWel Contractor f Date`
Brsignin,�,this•1orm.lherehr re+etifr that nine c�ell(s1 sas(wrrn)rnastruc•red in arcordmu•e t.irG
7.Is this a repair to an existing well: ❑Yes or !]No PU VC.1C VC.010n or d-1 XCAC 02C.n200 Wdl Cormtr uction Standards and that a com•
q'rhis is a repain fill our known well consinrcfinn infannarinn and explair the narurr•nfthe of This record has/mnprorided to rho v.rll owner.
repair rnrder#21 remarks section or on the back ofrhit form. m 23.Site diagra or additional well i 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
construction•only i GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:,_ �tS (fL)
Fur ma triple nx//s list ruff depi/ts ifdi ferent(ernmple-3@Q00'and.? 100? Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below to of casino•40 24a. For U Wells: Original fo 4 to Division of Water Resourm (DWR),
p �,. (ft.)!j outer level is above casing,use"+" Formation Processing Unit,1617 M I SC,Ralei&NC 27699-1617
11.Borehole diameter:6 118 24b.For Injection Wells:Copy to DWR.Underground Injection Control(TUC)
(m_) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary_cable•direct push,etc.) county emzronmenral health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over;100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gent) Method of test:Air Lift Permit Pro.am,1611 MSC,Raleigh,INC 27699-1611
44,,
13b.Disinfection type: ChIOr. Tabs Amount: 1 1/2 LUs
Form GW-1 North Carolina Dcpanmcnt of Enviroruncntal Quality-Division of Water Rosourccs Revised 6-6-201A