GW1-2022-00183_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD(GW 1) �
For Internal Use )nly:
1.Well Contractor Information: "" .r^ r •�r_, r
V +�
Joseph Bailey
ER ZONES
Well Con tractor Name D_ _ FROM TO DESCRIPTION
ON
UO /�19 ft. ?�ft. r/22'jrJ/IG
NC Well Contractor Certification Number M y O D"OG
B & K Well Drilling Inc <15.OUTER',CASING;for.•iatilticasedwells ORLINER ifa""lkabla
FROM TO DIAMETER THICKNESS MATERIAL
Company Name �j ft 6112 in. SDR21 PVC
l I I /!�J 7'6:INNERCASINGORTIJSING` euthei msl elosed t
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC.County.State.Variance,etc.) ft. ft m.
3.Well Use(check well use):
Water Supply Well: 17 SCREEN,>:°
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 6.
[3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft ft* to
Industrial/Commercial Residential Water Supply(shared)
18:GROffr-;a"
Irti ation
FROM TO MATERIAL E PLACEMENT METHOD AMOU
Non-Water Supply Well: V r
Monitoring Recovery ft ft
Injection Well: ft. ft. /
Aquifer Recharge Groundwater Rcmediation ft. ft
Aquifer Storage and Recovery Salinity Barrier 19:'SANDIGIYAVEL PACK rfa' cable -t,
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer Z0:°DAILIING;LOG'aFfacfi sdililioiiaisheets d.'ceces
Geothermal(Heatin Coolin Retum) Other(explain under#21 Remarks) FROM TO DESCRI 10N(color,hardness,soil/rock a}T in size.etc.)
ft /') ft.
as / v
4.Date Well(s)Completed: Well ID#�o-�J ft.
5a.Well Location: ll ft y ft
lfD�YlGS dG�� A;A ft ft Q�?
Facility/Owner Name Facility ID##(if applicable) ft• ft. S �G
l G r✓ft. �/)
Jr,� ft.
Physical d City,and Zip ft. v ft.
County Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif lion:
N W r
6.Is(are)the well(s)oPermanent or Temporary e o crtificd Con for Date
y signing this form.1 herehv ce ii that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or gi YVo with 15A 'his
01C.0100 or IS. CAC 02C.0200 Well Construction Standards and that a
If this is a repair•fill out known well construction information and explain the nature of Ike copy of this record has been provided to'the well owner.
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional welt 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also;a ttach 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 if different(example-3@a 200'end 2Q100')
construction to the following:
10.Static water level below to of casin 40
If water level is above casing,use'•+p g•
" (ft) Division of Water Resources,Information Processing Unit,
i6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: (n.) 24b.For Iniection 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
? 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) IM Method of test: / 24c.For Water SuoDly&Iniection Wells: In addition to sending the form to
Chl(JI the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1l2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Dcpartmcnc of Environmental Quality-Division of Water Resources'
Revised 2-22-2016