GW1-2022-00188_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
t
Joseph Bailey .Ia;WATEXZONEs-q �� � .r•, � � � ��
Well Contractor Name FROM TO DESCRIPTION
3271-A ft. / ft. i�;�9 j- g- brc 7.0.7•e
NC Well Contractor Certification Number l�1 ft. /is'R• i !'
7
ISIO.UT Tr
UT'ER`CASINGl fobmalh-c`
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
D ft: 1 ft. 6112 i in SDR21Jfek# k r�l
Company Name
4 �l'6INNERCASiNG ORTUBING: e6tlteYrisal!'i losed-lub
2.Well Construction Permit#: 'l FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i. .VIC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): Q � ) ft ft in.
Water Supply Well: 17:SCREENr,;. h:
n FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL v
Agricultural �Muni� a}tPtlblid' 2l'2� ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(sing le) ft ft to
Industrial/Commercial pnti2CWa-Isr SuNply<S l71 aze
ge '18'sGROUT.. = .. ,�.,. .oY€,gsV.. .• � ,z .:.r..,,... ,.a..r. _.,.r.a_ .:�
Irrigation aft `r FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. Qr ft 'eT vl►
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [3Groundwatcr Rcmediation
Aquifer Storage and Recovery SalinityBarrier 19:"SAND/GRAVEL•FAC1C a Iicible, ,
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20'DRILLINGUOG attach aildltiouslsheets N.'tiecessa ' "
FROM TO DESCRI ION(color,hardness,solllrock ri e, rain size,etc.)
Geothermal(Heating/Cooling Conlin Return) Other(explain under#21 Remarks) FROM
ft. t o ft. soy/
4.Date Well(s)Completed:yLoll Weli 1D# 0 ft. eT ft. y,goi
//ova✓ c,
SaYY.Well Location: ft. y0 ft. CC
f-iO C f)L. 0711 1dL S ft. ft Pul W`I s4 741
17
Fac ity/Owner Name Facility ID#(if applicable) ft. O ft Q G
.Q� s t2,� ft ids-it. - o
Physical Address,City,and Zip ft. ft.
21:REMARKS:;' _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification:
N W p�p�
6.Is(are)the well(s)oPermanent or OTemporary ure of rtific I Con c r, arc
B signing this form, !hereby rtify'lhal the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or !o ith ISA NCAC 02C.0)00 or ISA NCAC O2C.0200 Well Cmulnrction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has 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 OW-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: (O 0,5"0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'attd 2@I00) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Res l urces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in.) 24b.For Iniection Wells: in addition 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 Resource!,Underground Injection Control Program,
FOR WATER SUPPLY/WELLS ONLY: I 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) v Method of test: r)ic kk 24c.For Water Supply&InieWon Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constructionp to the county health department of the county
where constructed. If
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016