GW1-2022-00191_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey ,: 1a:WATER°zoNEs • 4
p',.-o.., FROM TO DESCRIPTION
Well Contractor Name Z ,, +i +
Fpa ;jam,F� r ft. fL I i/''
3271-A r ] t
(� / t 4 re
Dr NC Well Contractor Certification Number L 2022 /
&OUTER:CASING.for multi sed-:wells OR LINER•if u liable
B& K Well Drilling Inc In'i—mi-.f3�1 .�T 1 ` FROM TO DIAMET0, THICKNESS MATERIAL
Company Name .Q"L� 1. a ft' ft' 6112 to SDR-21 PVC
Li
��r,N�/ 16ANNER-CASING OR'TUBING" `eothermal.closed-loo
2.Well Construction Permit#: ��(f4// FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in. (' G
'+ t7
3.Well Use(check well use): ft. ft. in.
Water Supply Well: A7.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.�
Geothermal(Heating/Cooling Supply) t enttal Water Supply(single) ft. ft. in.,
Industrial/Commercial Residential Water Supply(shared) 18:GROUT a,, �'`'
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: ft. old/r ft. d�
Monitoring DRecovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVELPACK if a llcsW
[ -
Aquifer Storage and Recovery 3 Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
i
Geothermal(Closed Loop) Tracer 20. RILLING LOG attach'additionsl"sheets if oecessar'
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM I TO DESCRIPT N(color.hardness,soiltrock type rain size,etc.)
/j ft. ft.
4.Date Well(s)Completed: Well ID# v ft. 1 fr. ��d✓ 50! JD�
5a.WellLocation: ft, rl ft. R
�o low ,m 1117d i p ft. d ft. o /
Facility/OwwnerrNamee I Facility
IID#`(if
`aappplicable h ft' Cj17 LO &-�
Le • /r,�7/J 44 A1% �a�!/. VK. t�0��/ ft. ft.
ft. ft.
Physical Ac ress,City,and Zip
21.REMARKS',,..;:, ,.
'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.Certitlea
N W /O
1,3162,
6.Is(are)the well(s) Permanent or Temporary ature of rtified Well Contra or Date
y signing his form,I hereby cer' that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
If this is a repair,fill out!mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: I SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 0 (ft.) 24a. For All Wells: Submit this foal! within 30 days of completion of well
For multiple wells list all depths ifdierent(example- 00'and 2@100) 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 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
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
13a.Yield(gpm) Method of test: lY f I Fr 24c.For Water Supply&Iniectioni-Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to tie county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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