GW1-2022-00238_Well Construction - GW1_20221216

Print Fof
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey I4:-WATER ZONES. ;-11-1 °
Well Contractor Name FROM TO DESCRIPTION _
3271-A 7��
ft. ft. Tu_p
mbe
NC Well Contractor Certification Number b ft. X C/04// �G /i
J5.-0UTER CASING for multi-csiscd wells:OR IN R if a livable
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. !� ft. 61/2 in• SDR-21 PVC
Company Name (�
_ 16.INNERCASINGzORTUBING tgeothermalciosed-loo"%�__
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.
px
Water Supply Well: 17..SCREEN',' °'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single)g ) ft. ft, rn.
Industrial/Commercial Residential Water Supply(shared) 18i GROUT '
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT+
Non-Water Supply Well:
Monitoring Recovery ft. ft. LV
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SANDIGRAVELPACK if_a `lieab'le
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .,20-DRILLING SLOG attach additionsCsheets if
FROM '1'O DFSCRI TION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft. e
4.Date Well(s)Completed:, Well ID# ft. ft.
ft. ft.
Sa.Well Location:
CA
acdity/Owner Name Facility ID#(if applicable)
C of e- 1 d Aanyi 7 -
Ph�Address,City, Zip ^ ft. ft.
3 1.REMARKS,; �.§ y,y
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.Certification:
N W
6.Is(are)the well(s) Permanent or OTemporary Sig lure of crti ed I Contractor bill I
signing this farm,I hereby cer that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or Jp5o with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or an the back of this farm.
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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/fdierent(example- @100'and 2@100') construction to the following: j
10.Static water level below to of casing:40 p g: (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6 1/8 ( i
11.Borehole diameter: (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
(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) 3 AlaMethod of test: 24c.For Water SuoDiv&Inielti In Wells: In addition to sending the form to
the address(es) above, also submid one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction tolthe 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
I � ,