GW1-2022-00198_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD (GW 1)
For Internal Use Only:
1.Well Contractor Information:
I
Joseph Bailey
Well Con tractorName i fl e tEr'i -' TI
FROM TO DESCRIPON
3271-A e fl�<-v' m= � r Y ft.
NC Wcll Contactor Certification Number DEC 1 L: 2022 f4 fr•
B& K Well Drilling Inc 1si:ouTER!.cAs1Nc<foririulti ca9ed:welLs.OR•L'INER if a`•ncable
_-cr,7::5e'.��1 �I�,•C=:�.v �:']unil FROM TO DIAMETER
Company Name ✓tf a,- ;5; fG p IL I In. THICKNESS MATERIAL
�/ 61/2 SDR-21 PVC
�(� 76 INNER°CASING OR:TI7BING ed;I
2.Well Construction Permit# eamermal cles
: (f 111 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.Stare.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
[Geothermal
Supply Well:CDlhlI31 FROM TO DIAMETER SLOT SIZE THICKNESS MATERIL0Municipal/Public ft.(Heating/Cooling Supply) esidential Water Supply(single)
ft. fr. in.
strial/Commercial Residential Water Supply(shared)
1ff.:GROUT
Irri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT••
Non-Water Supply Well: ft ft.
Monitoring Recovery ft ft n W
Injection Well:
Aquifer Recharge Groundwater Rcmcdiation ft' ft.
rc19:'SAND/GRAVELPACK
Aquifer Storage and Recovery Salinity Barrier
rfa ¢able
FROM TO MATERIAL EMPLACEMENT!1fETHOD�
Aquifer Test IDStormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20zDRILIID1GIOG`attachsdditidn9isbeetsif'ne
Geothermal(Heating/Conlin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness�soiUrvck tv in. in sire,etc.
ft. fr• � .J lO
4.Date Well(s)Completed: Well ID# ft..
5a.Well Location: ft. �ft.
H�I»95 ?a/11}JmtS l QfL ft.
Facility/QwnerName Facility ID#(ifapplicable) h ft.
Sk
�
Physica�ress,City,and Zip ft. ft
yy
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.Certffica' n: J `�
N W
6.Is(are)the well(s) Permanent orTemporaty _n of Cc ficd W ontra t Date `
B signing ihis form.I herehv cer, thal;the well(s)was(were)cunsn•ucted in accordance
7.Is this a repair to an existing well: []Yes or Vp di 15A NCAC 02C.0100 or, 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature Of1he copy ofthls 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-I 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: -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
construction to the following:
10.Static water level below top of casing:40 ft
Ifwater level is above casing,use +" ( ) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24 j
b.For Injection 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) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Color Tabs the address(es) above, also submit one;copy of this form within 30 days of
136.Disinfection type: Amount: 1 1/2 Lbs completion of well construction to thel county health department of the county
where constructed.
I Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016