GW1-2022-00193_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
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Well Contractor Name l�: � •' ) 1 FROM TO DESCRIPTION
3271-A d et. ft. iSM'f a TGfr 220/_
'J T NC Well Contractor Certification Number D r C j �1 2`(� C�' �'L_ (� fL � ft. ' p l�Ye_ 2mC
rt-f130UTER;CA3ING'fomiiltc ed':weHs'ORL`INER``.ita"licable i:�a � ,.>��;.
B& K Well Drilling Inc Ifi C�i• �1�� �t -zs +.'•.-�Ur,',,l FROM TO DIAMETER THICKNESS MATERIAL
�,,,� 0 ft //G ft. 6 112 to SDR 21 PVC
Company Name /n✓ 77
I _ 3a �03� ��5:'1NNER CA51NG'OR�'fUB1NG eatheimal`cio"sed-loo ��:�: �ie�'�x. ��&�,;e;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: r.17:SCREEN R ,__ '%m____' AV 'i ..a,3.. ,.. .I
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [Mun ipaMblic ft ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft.
Industrial/Commercial Residential Water Supply(shared)
)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
%1-
AUI
:)Monitoring Recovery ft. ft.
ti-
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer :2t1 D1211 LING`.IOG attacfiadd[tioosk;sheelsifaecesxsxrlx kt .h
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM ft. TO DESCRIPT N(colop hardness,soil/ruck type,grain size,etc.
/G/y—
4.Date Well �j �Q� W s)Completed:� I ell ID# L lt3 It.
ft. r{ re
ft '
Sa.Well Location: ./� l / ! �
l�T ft. iS ft G/
Aa.ilit!y!0w;er Name Facility ID#(if applicable) 60
166 JI-Ve 1l1<4"-e ft.
Physical Address,City,and Zip ft ft
-ell co,
County Parcel Identification Na'(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific n•
N W A13112
6.Is(are)the weil(s)oPermanent or OTemporary rith
uro ofC ifi Con etor Datc
ning[is form,1 hereby c "i the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or p< 5A NCAC 02C.0100 or 15 02C.0200 Well Construction Standards and that a
If this 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#21 remarks section or on the back ojthis 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 I 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: (l r (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@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in.) 24b.For Injection 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.)
1
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: �� % 24c.For Water Supply&Injection 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: t 1/z Lbs completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016