GW1-2023-01779_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
I.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
Well Contractor Name FROM To DESCRiFFION
3271-A 0 ft' j ft !=
NC Well Contractor Certification Number
15.01JTER.CASING.forrittilti ed:wellsOR LINER"i€a llcable .., .
B &K Well Drilling Inc FROM TO DIAMETER I THICKNESS MATERIAL
Company Name ® ft IL 1 6 1/2 1 in. SDR-21 PVC
16.4NNER CASING OR TUBING.Qeotfiertlral closed-loci
2.Well Construction Permit#: V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.C'nrotty.State. orlon e,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: IT SCREEN.''.
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Munici aI/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft ft. in.
IndustriaUCommercial Residential Water Supply(shared)
18:GROUT :.i'> .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft �davr
Monitoring Recove
Injection Well: ry ft. tt.
:)Aquifer Recharge �Groundwatcr Remcdiation ft. ft.
Aquifer Storage and Recovery [)Salinity Barrier 19:SAlrD/GRAVELPaCK da cable ' a:: "°•* :p.nri,gR,r,.; ;...
Ty FROM TO MATERIAL t ' y,I EMPI,.'CENIENVMETIIOD,�)
Aquifer Test []Stormwater Drainage ft. ft v
Experimental Technology 13Subsidence Control ft. ft. FF8 9, l
23
Geothermal(Closed Loop) E3Tracer
20:DR1LI:INGLOG attachaddifitinalslieefsifae- .'_• ..:,.,, .:,
Geothermal(HeatingfCooling Return) nOther(ex lain under#21 Remarks) FROM To DESCRIPTIONS�dto'd'HAidhas 4df ck'' t a�i��
ft. ft. C Jl:lis ;
4.Date Well(s)Completed: � Well ID# j ft. ft. rO
5a.Well Location: ft.
ft.
G �
ft_ ft
Faciiliittyy/tOwwnneerrName Facility
)ID#((iiff arpplicablle))) Q /
�r Y///s /ji N` AIr ft. fL
Physical Address,City,and Zip
21.REMARKS
County Parcel ldcntification No.(PIN)
j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific on:
N
W
6.Is(are)the well(s)oPermanent or Temporary SI ofC ific Con ct Date-
signing this form,l herebv rd."that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or E;�Vp with 15A NCAC 02C.0100 or SA CAC 01C.0100 Well Construction Standards and that a
ljthis is a repair,fill out known well construction information and explain the nature ofthe copy oJ'thrs record has been p .ed tv'the well owner.
repair under#21 remarks section or on the back ojthis 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 ofwells construction details. You may also'attach additional-pages ifnecessary.
drilled: 4 i,
ft SUBMITTAL INSTRUCTIONS'•
9.Total well depthst below land surface: ( ) 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 1@1001
construction to the following:
10.Static water level below top of casing:40
(ft.) Division of Water Resources,Information Processing Unit,
ljwarer level is above casing,use"+" ft. 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
12.Well construction method: Air Rotary above,also submit one copy of th�s 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 Tenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1( 24c.For Water SuDDIv&Iniectio I Wells: In addition to sending the form to
ChlorTabs the address(es) above, also submit bne copy of this form within 30 days of
13b.Disinfection type: Amount:
1 1t2lbs completion of well construction to, the county health department of the county
where constructed.
i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016