GW1-2022-00194_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey a .emu. s- rF, q.,, 14.�WATERZONES ,
Well Contractor Name �-`i" i!,ar FROM ft. TO DESCRIPTION
t. t�m ft.
3271-A DEC L 2022 ft. et.
NC Well Contractor Certification Number ]S;.OUTER CASING foe multi-cased wells OR LINER if h licable
B&K Well Drillin Inc (..Tii FROM TO DIAMETER' THICKNESS MATERIAL
Company Name v���yyye c. 0 ft. ft- g 1/2 in. SDR-21 PVC
16-INNER.CAf�SING�OR_TITBiNG' epthermalclosed-166� +,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN _.�,g
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OdMun 'paUPublic tt. ft. in.
i
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) IS GROUT.
Irri ation FROM TO MATERIAL E PLACEM✓NT METHOD&AMOUNT
Non-Water Supply Well: ft. O ft. �
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
19..SAND/GRAVEL-PACKi ifa `livable '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20rDRILLING LOG attach additionalsheetsif hecessar
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,.etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) ft, ft. Sdi
4.Date Well(s)Completed: Well ID# 3A2
ft. f­ft. rav4 -,Q*
5ajW/ell Location:
rt. rt. SQt6
Facility
1/ID(/#(t'if applicable)
fFacility/Owner Name ffttt.
V ">TA7"gs /pl N` /0
calAr Z Phys e� t ip . S21'REMARK
tffttt...IF
Wq
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
P
N W r i�
6.Is(are)the wells) Permanent or Temporary Sig ure of C ified Well Cont
Date
— s B signing this form,1 herelN that tie iiell(s)was(were)constructedin accordance
7.Is this a repair to an existing well: DYes or 'Ywith 15A NCAC 02C.0100 orCAC 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 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
(J /
9.Total well depth below land surface: t`,� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(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 1/8
(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 Resources,Uniderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
aa i
CJ 13a.Yield(gpm) /7W Method of test: k4ffrl 24c.For Water Suably&Iniection'Wells: In addition to sending the form to
V. 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 the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016