GW1-2022-00226_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
P Y 1'4.WATER-ZONES'°
Well Contractor Name FROM TO DESCRIPTION
3271-A rt. �6 ft.
NC Well Contractor Certification Number a 7 u 0 ft. q ft. �G
15tOUTERCASING foi•multi-vased'svclls'ORLINER ifa"livable'
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL <
® ft, l ft. 61/2 11O SDR-21 PVC
Company Name
l 11Ae��(,t/�� /+ °16.:INNERCASING'OR'.TUBING" eothermal closed-ioo '_
2.Well Construction Permit#: 1 le/I. v /_OP006 /3� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernnts(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Mu I/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ' It. I. C 141 S
Monitoring EIRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK_(if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer %20i DRILLINGLOG.attach a�tlitiou`atsheets it necessa` �:;,;
Geothermal(Heatin Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRI Jr1ON(color,hardness,soil/rack a rain size,etc.
- qq /0 f1. / .Sa,
4.Date Well(s)Completed: ��—�d� �# ft. 0 ft. re-4�41 4,
5a.�Well
Location: ft. ft. /6�0� 141_27 a tv
amk ft. O -t �i
Facility/Owner Name Facility ID#(if applicable) D ft. ft. O rery Q /
ft. 0- f
Physical Address,City,and Zip ft, ft. '
/r /h /� (M{ y) 11.;REMARKV
County Parcel Identification No.(PIN) G—
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t; LULL
well field,one lit/long is sufficient) 22.Certification: —
unil
6.Is(are)the well(s) Permanent or OTemporary Si me o erti d Well tractor I Datc
signing this form,I •ebv certify lhalithe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or with 15A NCAC 02C..0100 or 15A NCAC 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
9.Total well depth below land surface: L �� (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@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 /8 (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 iform 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 00, Method of test: i f '2r 24c.For Water Supply&Iniection'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 the ccounty health department of the county
where constructed. I
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016