GW1-2022-00199_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
I.Well Contractor Information:
Joseph Bailey
Well Con •- ,14�i1TERZUNES� v�✓r .�,:,� ..a�,. M� a�,„�a;�� c.,. ;r c a: �::
ontractor Name 'ppf rr Nr * °y FROM TO DESCRIPTIO
' "�. '._ Elh.>'IS t cv ® '�—.r' O ft. r ft.
3271-A v y / Gr,,L
n ft ft
NC Well Contractor Certification Number D h C 1 �� 202/n
15 D13SERGA SIN G formaltr-cased veils"ORIINER i€a livable`s ' y
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS I MATERIAL
Company Name r ' '''`"" 61/2
P Y r;,g uv� v 0 ft. ft in. SDR21 PVC
_A6UNNEit45ASINQa,0BTUB "o[itermaiclosedl ,
2.Well Construction Permit#: �� t�` J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
:]Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn �Munici a Public, ft. ft. in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single)
ft ft to
IndustriaUCommercial Residential Water Supply(shared) ,
..�.a,,;,;�,'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
MonitoringRecovery ft. ft.
Injection Well:
:)Aquifer Recharge oGroundwatcr Rcmediation ft ft
Aquifer Storage and Recovery19;SAND/GRAVECTAC C da
�SalinityBarrier FROM TO MATERIAL EMPLACEMENTAfETHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology E38ubsidence Control ft. ft. '
Geothermal(Closed Loop) OTracer 20 11RILLING LOG,atfacladdraoiiiil"sheets
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVruck a rain size etc.
ft. f ft.
4.Date Well(s)Completed: �Q Well ID# d l3 ft 0 ft.
Sa�.(]Well
Location: T/ ' ft. 0 ft
?,'4 Ile)
Facility/Ow er Name Facility ID#(ifapplicable)
1551Ayllo
Physical Address,City,and Zip ft. ft.
ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/Iong is sufficient) 22.Certifica
N W
6.Is(are)the well(s) Permanent or Temporary Signat c of C ific Well Co tra at
&?/2—,/2�
By fining this form,I hereb rt fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or o wi ISA NCAC 02C.0100 o SA NCAC 02C.0200 Well Construction Standards and that a
jthis is a repair,fill out known well construction information and explain the nature ofthe ct ofthis 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/I)PT 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 ofwells construction details. You may also attach additional pages ifnecessary.
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 ijdifferent(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,
ljwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /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
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
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: I/ 24c.For Water SUDDIv&Iniection 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 construction to the iounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

ICHD Environmental` Health Division INSPECTIONS:704-664-3703 Statesville Office:(704)878Z305x3456-Mooresville office:(7o4)66o-3625
c5W Y xazz
PRIVATE DRINKING"WATER WELL PERMIT# i5 5 PIN# t_1 S t t�z - 41 05 Type of Permit Ldrele one) New Repair Abandonment
APPLICANT/OWNER N E: c Bra trs 11. ADDRESS. 11G NC. 2 (D PHONE:_-X4--50a-SSix+
DIRECTIONSTOSITE:�NC-.i QS`1"t�ICI� tlPylil"+=1 We,?Akr_Nd 3S 1
SITEADDRESS: 341 r'Cl,-Routhc: -Zs iU.ko SUBDIVISION: : . �
SECTION/LOT: "—/
- 7 �
tnitiahs[te Sketch CALL, _66370 3 for
4-
Grout or Well'lead lnspectroris
�� Between 8 9arro
.- GROUTING RESULTS
Total Depth
�`-^�.,_ Depth of Casing
Yield
a
Notes:
�
f 'jn i C4 �r:
CC
- - - )O GPm -
PERMIT CONDITIONS/COMMENTS: r'Oflt,w c,li n1C tintQ.11 V1J1ks. �ri ii i�1Sjr 0 e�lell ChYQc�
WELL PERMIT ISSUED BY: DATE:el-Zj-2.2- (Permit is.valid for 5 years from date issued.This permit may be revoked if it is determined there has been
a material change in anyfact or''cumstan upon which the permit is issued. Actions of the employees of the Iredell County Health Department shall in noway be taken as a guarantee that this well will produce water
of any particular quantity,or quality orfor any amount of time. Employees of the Iredd County Health Department assume no liabilityfor any damages,either director consequential which maybecaused by this well.)
Well Contractor: CONTRACTOR CERT#t: GROUT INSPECTION BY: DATE:
OR CERTIFICATION OF GROUT NOTWITNESSED BY DEPT: DATE: WELLHEAD INSPECTION BY: DATE:
WELLHEAD INSPECTION(check when completed): 'GROUT TO GROUND SURFACE❑ WELL CONTRACTOR ID PLATE❑ PUMP INSTALLER ID PLATE❑ SAMPLE PORT❑
ACCESS PORT/VENT 0 WELL SEAL❑ WELL HEAD 121NCHES/PITLESS ADAPTOR 8 INCHES ABOVE GRADE O
CERTIFICATE.OFCOMPLEriON BY: DATE: WATER SAMPLES BY: DATE:
Attachments:Form GIN-1a(reouired.exceot for abandonment)❑ Form GW-30 O Water Sample Results❑ Plat❑'GALL 7O4'6B4 3TQ3 to schedule ,duI:6 w 11 head rrtspections between 8 9am